DUPLICATE 


HX00019283 


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~RG  491 


T?61 


Columbia  Winibmitp 


Hrpartnwnt  of  #urg?ry 
(Sift  nf  Br.  3Iospu1)  A.  Slakr 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/diseasesofbreastOOrodm 


DISEASES  OF  THE  BREAST 


RODMAN 


DISEASES  OF  THE   BREAST 


WITH 


SPECIAL  REFERENCE  TO  CANCER 


BY 

WILLIAM  L.  RODMAN,  M.D.,  LL.D. 

PROFESSOR  OF  SURGERY   IN   THE   MEDICO-CHIRURGICAL    COLLEGE   OF    PHILADELPHIA;    PROFESSOR 
OF  SURGERY   IN   THE  WOMAN'S   MEDICAL  COLLEGE   OF   PENNSYLVANIA;    SURGEON   TO   THE 
MEDICO-CHIRURGICAL   HOSPITAL,    THE  WOMAN'S    COLLEGE   HOSPITAL,    THE   PHILA- 
DELPHIA  GENERAL  HOSPITAL,   THE  JEWISH   HOSPITAL,   AND  TO  THE  PRES- 
BYTERIAN    HOSPITAL;     FELLOW     OF   THE    AMERICAN    SURGICAL 
ASSOCIATION;    MEMBRE    DE    LA    SOCIETE    INTERNA- 
TIONALE  DE   CHIRURGIE,    ETC. 


WITH  69  PLATES 

OF   WHICH    12    ARE   PRINTED    IN   COLORS 
AND  42  OTHER  ILLUSTRATIONS 


PHILADELPHIA 

P.    BLAKISTON'S   SON   &   CO 

1012  WALNUT  STREET 
1908 


Copyright,  ioo8,  By  P.  Blakiston's  Son  &  Co. 


Printed  by 

Tin  Maple  Press. 

York,  Pa. 


DEDICATION. 


TO  THE  STUDENTS  AND  ALUMNI 

OF  THE 

FOUR   MEDICAL  SCHOOLS 

IN  LOUISVILLE  AND  PHILADELPHIA 

WHOM  IT  HAS   BEEN  MY  PRIVILEGE 

AND  PLEASURE  TO  INSTRUCT 
DURING  THE  PAST  TWENTY  YEARS 
THIS  VOLUME- 
IS   AFFECTIONATELY  INSCRIBED. 


viii  Preface. 

Doctors  Ma.  Parland  and  Kelly,  and  their  assistants  have  placed 
me  under  obligations  to  them  for  making  microscopical  examina- 
tions of  tissues  removed  at  the  time  of  and  subsequent  to  operation. 

Dr.  Henry  S.  Wieder,  Demonstrator  of  Surgical  Pathology  in  the 
Medico-Chirurgical  College  is  largely  responsible  for  the  chapter 
on  Tumor>  in  General  and  their  classification.  Dr.  George  E. 
Pfahler,  Medico-Chirurgical  College,  has  kindly  supplied  many  of 
the  photographs  reproduced,  and  my  clinical  assistants,  Drs.  Stil- 
well  C.  Burns  and  Harriet  L.  Hartley,  have  rendered  valuable  as- 
sistance in  the  preparation,  operation,  and  after  treatment  of  my 
patients. 

The  Publishers,  P.  Blakiston's  Son  &  Co.,  have  been  most  liberal 
in  illustrating  the  book,  and  Mr.  I.  A.  Hagy  of  their  staff  particu- 
larly has  been  most  obliging,  suggestive,  and  helpful  throughout. 

Mr.  Charles  F.  Bauer  has  placed  me  under  obligations  to  him 
for  the  illustrations  accurately  portraying  the  several  steps  of  oper- 
ative procedure. 

My  secretary,  Miss  M.  G.  Cline,  has  greatly  assisted  me  in  read- 
ing proof  and  in  many  other  ways. 


CONTENTS. 


Anatomy  and  Physiology 1-26 

Description  of  the  breasts,  1;  blood-vessels,  5;  lymphatics,  10;  nerves, 
13;  variations  from  the  normal,  14;  the  male  breast,  15;  function,  16; 
persistent  lactation,  17;  development,  17;  normal  lactation,  18;  the 
alveoli  during  lactation,  22;  involution  of  the  breast,  25. 

Inflammatory  Diseases 27-42 

Congestion  and  engorgement,  27;  inflammation  or  mastitis,  28;  paren- 
chymatous mastitis,  30;  retromammary  abscess,  30;  treatment  of  mas- 
titis, 32;  chronic  mastitis,  35;  chronic  abscess,  41. 

Tuberculosis 43_5^ 

Frequency,  43;  forms,  43;  etiology,  45;  pathology,  46;  association  with 
carcinoma,  48;  symptoms,  51;  diagnosis,  52;  prognosis,  53;  treatment, 
54;  operation,  54;  Wright's  bacterial  vaccines,  55;  Bier's  passive  hy- 
peremia, 56. 

Syphilis 57-62 

Frequency,  57;  modes  of  infection,  57;  forms  of  mammary  chancre, 
58;  differential  diagnosis  of  mammary  chancre,  58;  secondary  and  ter- 
tiary lesions,  60;  differential  diagnosis  of  gummata,  61;  diffuse  syphil- 
itic inflammation  of  the  breast,  61;  method  of  staining  for  the  spiro- 
chaeta  pallida,  62;  treatment,  62. 

Actinomycosis 63 

Cysts 64-82 

Varieties,  64;  single  retention  cyst,  64;  lymphatic  cyst,  65;  general  cys- 
tic disease,  66;  galactocele,  74;  hydatid  cyst,  79;  dermoid  cyst,  81;  se- 
baceous cyst,  82. 

Diffuse  Hypertrophy 83-87 

Keloid 8S-90 

Tumors  in  General 91-102 

Nature  and  origin,  91;  Virchow's  theory,  91;  Cohnheim's  theory,  91; 
Senn's  theory,  91;  Ribbert's  classification,  94;  clinical  varieties,  95; 
characteristics  of  benign  tumors,  95 ;  characteristics  of  malignant  tumors, 
96;  relative  frequency  of  mammary  neoplasms,  99;  age  incidence  of 
benign  mammary  neoplasms,  100;  classification  of  benign  mammary 
neoplasms,  101;  classification  of  malignant  mammary  neoplasms,  102. 

ix 


x  Contents. 

Fibro-epi  i  in  ii  \i.  Tumors 103-146 

Historical  considerations,  103;  synonyms.  104;  etiology,  106;  peri- 
ductal  fibroma  (fibroadenoma),  106;  [fibro-cystadenoma,  112;  papil- 
lary cystadenoma,  1 14;  simple  adenoma,  121;  prognosis,  122;  treat- 
ment, 125;  plastic  resection  of  the  breast,  126. 

Lipoma     147-149 

Enchondroma    150-152 

M\  XOMA 153 

Angioma JSS-^Q 

Endothelioma 160 

Sarcoma 161-172 

Frequency,  161;  etiology,  162;  pathology,  163;  age  incidence,  164; 
varieties,  165;  myxosarcoma,  165;  periductal  sarcoma,  166;  pure 
sarcoma,  166;  symptoms,  166;  diagnosis,  169;  prognosis,  171; 
treatment,  171. 

Carcinoma 1 72-371 

Etiology,  173;  germ  theory,  173;  influence  of  sex,  175;  age  incidence, 
176;  frequency  in  young  women,  177;  racial  influence,  719;  hered- 
ity as  an  etiological  factor,  180;  relative  frequency  in  single  and 
married  women,  181;  influence  of  traumatism  and  inflammation, 
182;  bilateral  carcinoma,  183;  pathology,  186;  varieties  of  mam- 
mary carcinoma,  186;  adenocarcinoma,  186;  medullary  carcinoma, 
192;  carcinoma  simplex,  192;  scirrhus  carcinoma,  195;  cancer  en 
cuirasse,  195;  atrophic  or  withering  cancer,  196;  gelatinous  or  mu- 
coid carcinoma,  199;  carcinomatous  cyst,  199;  the  dissemination  of 
carcinoma,  200;  involvement  of  the  axillary  lymph  glands,  201;  in- 
volvement of  the  supraclavicular  glands,  202;  involvement  of  the 
mediastinal  glands,  the  spinal  cord,  and  the  pectoral  fascia,  205; 
Handley's  theory  of  permeation,  206;  dissemination  by  the  blood 
stream,  211;  invasion  of  the  pleura,  214;  pulmonary  metastases,  214; 
metastases  to  the  bones,  214;  metastases  in  the  brain,  217;  involve- 
ment of  the  pelvic  organs,  217;  symptoms,  217;  tendency  to  conceal 
tumors  of  the  breast,  218;  signs  of  beginning  carcinoma,  219;  re- 
traction of  the  nipple,  220;  fixation  of  the  breast,  220;  enlargement 
of  axillary  glands,  222;  ulceration  of  the  breast,  223;  constitutional 
symptoms,  224;  progress  of  atrophic  scirrhus,  225;  acute  cancer, 
226;  clinical  manifestations  of  cancer  en  cuira.cse,  230;  importance  of 
early  diagnosis  and  operation,  235;  method  of  examining  a  patient, 
241;  location  of  the  growth,  242;  absence  of  pain,  245;  age  in  refer- 
ence to  diagnosis,  246;  value  of  microscopical  diagnosis,  247;  injury, 


Contents.  xi 

inflammation,  and  heredity  in  reference  to  diagnosis,  248;  differen- 
tial diagnosis  from  fibro-epithelial  tumors,  249;  from  chronic  mastitis 
or  abnormal  involution,  249;  from  tuberculosis  and  syphilis,  250; 
from  sarcoma,  251;  from  cysts,  251;  prognosis,  253;  curability  of 
mammary  carcinoma,  254;  recurrence,  255;  operative  mortality, 
257;  treatment,  259;  caustics,  262;  trypsin  treatment,  263;  oophor- 
ectomy, 263;  history  of  the  operation  for  the  cure  of  mammary  car- 
cinoma, 266;  relative  importance  of  the  several  steps  of  the  operation, 
280;  technique,  282;  author's  method,  287;  postoperative  treatment, 
319;  plastic  operations,  322;  Warren's  operation,  323;  Jackson's 
operation,  326;  Dawbarn's  operation,  361;  Tansini's  operation,  363; 
palliative  operations,  368;  treatment  of  inoperable  cases,  370. 

Paget's  Disease  of  the  Nipple 372-380 

Index 381-385 


DISEASES  OF  THE  BREAST. 


ANATOMY  AND  PHYSIOLOGY. 

A  knowledge  of  the  normal  structure  and  relations  of  the 
breast  is  essential  for  an  adequate  conception  of  the  mode  of 
development,  extent  and  effects  of  the  neoplasms  and  other 
diseases  which  affect  it,  as  well  as  for  a  thorough  understanding 
of  the  principles  upon  which  their  rational  surgical  treatment 
depends.  Therefore  a  review  of  the  gross  and  minute  anatomy 
of  the  organ  will  be  given,  and  the  functions  so  far  as  they  bear 
upon  the  evolution  of  morbid  processes  afterwards  discussed. 

The  breasts  occupy  the  anterior  and  superior  aspect  of  the 
thoracic  wall,  one  lying  on  either  side  of  the  sternum,  in  front 
of  the  great  pectoral  muscles.  In  shape  they  are  hemispherical, 
although  as  the  result  of  repeated  child-bearing  and  nursing 
they  frequently  lose  their  original  contour  and  the  firm,  elastic 
consistence  with  which  they  are  characterized  in  young  women 
who  have  not  borne  children,  becoming  displaced,  pendulous 
and  flabby. 

At  birth  the  breasts  are  very  rudimentary,  and  remain  so 
until  puberty,  when  they  increase  rapidly  in  size.  The  average 
normal  dimensions  in  the  primipara  have  been  given  as  follows : 
length  4  to  4^  inches;  breadth  5  inches;  thickness  2  inches. 
These  figures,  however,  are  by  no  means  constant.  It  has  also 
been  observed  that  the  two  breasts  are  rarely  of  exactly  the 
same  dimensions. 

The  anterior  surface  is  convex,  smooth  and  regular,  present- 
ing in  its  center  a  dark  ring,  the  areola,  which  surrounds  the 

1 


Diseases  of  the   Breast. 

nipple  and  contains  from  twelve  to  twenty  sebaceous  glands, 
appearing  as  minute  elevations  upon  the  surface.  These  are 
known  as  the  tubercles  of  Montgomery.  Their  arrangement  is 
usually  irregular. 

Xot  only  does  the  skin  of  the  areola  differ  in  color  from  that 
over  the  rest  of  the  mamma,  but  it  is  also  characterized  by 
absence  of  subcutaneous  fat,  and  the  presence  of  a  layer  of 
muscle-fibers  beneath  it,  to  which  the  name  of  subareolar  muscle 
has  been  given.  Most  of  the  fibers  are  circular,  being  placed 
around  the  base  of  the  nipple,  but  there  are  also  some  radiating 
fibers  crossing  the  others  in  various  directions.  Contraction 
of  this  muscle  produces  erection  of  the  nipple. 

This  latter  structure  is  an  elevation  of  variable  size  and  shape 
situated  in  the  center  of  the  areola.  It  is  usually  cylindrical 
or  conical  in  form  and  ends  in  a  somewhat  rounded  tip  contain- 
ing the  orifices  of  the  galactophorous  ducts.  Beneath  the 
integument  of  the  nipple  transverse  and  longitudinal  muscle- 
fibers  are  found,  constituting  the  mammillary  muscle.  The 
former  compress  the  galactophorous  ducts  and  also  aid  the 
subareolar  muscle  in  protruding  the  nipple;  the  latter  cause 
retraction  of  the  nipple. 

The  posterior  surface  of  the  mamma  rests  upon  the  great 
pectoral  muscle,  from  which  it  is  separated  by  the  pectoral 
fascia.  A  layer  of  cellular  tissue  intervenes  between  the  apo- 
neurosis of  the  muscle  and  the  superficial  fascia  with  which  the 
gland  is  intimately  connected. 

The  glandular  substance,  with  the  exception  of  that  portion 
covered  by  the  areola,  is  completely  embedded  in  fat.  The 
subcutaneous  layer  of  fat  splits  into  two  portions,  one  of  which 
passes  behind  the  gland,  lying  between  it  and  the  superficial 
fascia,  and  the  other  passes  in  front  of  it,  filling  in  the  depressions 
between  the  glandular  lobes.  The  anterior  layer  is  very  thick, 
the  posterior  thin. 

The  gland  itself,  when  freed  from  the  superficial  structures, 


Anatomy  and  Physiology.  3 

appears  as  a  rough  irregular  mass  of  a  grayish  or  light  brown 
color  consisting  of  twelve  to  twenty  separate  lobes.  Elevations 
alternate  with  depressions.  The  anterior  mass  is  covered  by  a 
layer  of  connective  tissue  which  sends  prolongations  outward  to 
the  skin  and  downward  between  the  lobes  of  the  gland. 

In  former  descriptions  of  the  breast  it  was  usually  stated 
that  the  glandular  substance  extended  from  the  second  or  third 
rib  above  to  the  sixth  or  seventh  below,  and  laterally  from  the 
outer  side  of  the  sternum  to  near  the  anterior  border  of  the 


Papilla 


Fig.  i. — Horizontal  diameter  of  the  right  mamma.      {Morris'  "Anatomy.") 


axilla.  It  is  now  known,  however,  that  this  description  by  no 
means  always  accurately  defines  the  limits  of  the  organ,  for  it 
has  been  shown  that  prolongations  of  glandular  substance  may 
extend  upwards  toward  the  clavicle,  downwards  towards  the 
external  oblique  muscle,  inwards  to  the  sternum,  and  outwards 
into  the  axilla.  The  last  named  prolongation  is  very  common, 
and  is  considered  normal  by  some  anatomists.  Cusps  of  gland- 
ular tissue  also  sometimes  perforate  the  retromammary  fascia 
and  invade  the  substance  of  the  pectoralis  major  muscle. 


Diseases  of  the   Breast. 


Each  lobe  in  the  gland  is  provided  with  its  own  excretory 
duct,  which  becomes  dilated  into  a  small  sac  as  it  approaches 
the  nipple.  This  dilatation  is  known  as  the  lactiferous  sinus. 
As  the  sinuses  advance  towards  the  periphery  of  the  nipple 


Clavicle  — 


■•    Pectoral  fascia 

M 

Third  rib 


JBSj""  Connective  tissue 


First  rib 


Second  rib 

Pectoralis  minor 
Intercostal 


Pyramidal  process  _      pat 

Retinaculum  cutis 


._  Superficial  fascia 

"  Fourth  rib 

Kfci-     Fat 

■  Horizontal  plane 

....  Fifth  rib 


Sixth  rib 


External  oblique 


FIG.  2.— Sagittal  section  of  the  right  mamma  of  a  woman  twenty-two  years  old. 

(Morris,  after  Testut.) 

they  become  narrowed  again  and  perforate  its  tip  by  means  of 
minute  openings  about  0.5  mm.  in  width. 

The  lobes  are  made  up  of  lobules,  which  in  turn  are  composed 
of  smaller  structures,  the  alveoli  or  acini.    It  is  the  ducts  of  these 


Anatomy  and  Physiology. 


5 


alveoli,  very  minute  passages,  which  unite  to  form  the  larger 
galactophorous  ducts.  The  alveoli  are  lined  with  cubical  epi- 
thelium, as  are  also  the  minute  ducts  leading  from  them;  the 
main  excretory  ducts,  however,  are  lined  with  columnar  cells. 
Blood  Supply. — The  mammary  gland  receives  its  blood 
from  the  internal  mammary,  the  external  mammary  or  the  long 
thoracic,   the  superior  thoracic,   the  pectoral  branch  of  the 


Fig.  3. — Arteries  of  the  anterior  surface  of  the  breast.     First  type. 

(Adapted  from  Piet.) 

a.  Secondary  artery,    b.  Principal  artery,    c,  Secondary  artery. 

acromio-thoracic,    and    perforating  branches  from  the  aortic 
intercostals,  principally  the  second,  third  and  fourth. 

The  principal  blood  supply  comes  from  the  internal  mam- 
mary through  its  first,  second,  third  and  fourth  perforating 
branches.     It  has  usually  been  stated  that  these  branches  pass 


6  Diseases  of  the   Breast. 

directly  to  the  deep  surface  of  the  gland,  perforating  it  and 
sending  brandies  throughout  its  substance.  The  recent 
investigations  of  Pict,  however,  show  that  such  is  not  the  case. 
This  anatomist  has  found  that  the  perforating  branches  of  the 
internal  mammary  pierce  the  great  pectoral  muscle,  enter  the 
superficial  fascia,  and  then  become  distributed  over  the  anterior 


Fig.  4. — Arteries  of  the  anterior  surface  of  the  breast.     Second  type. 

{Adapted  from  Piet.) 

a.  Principal  artery,     b.  Secondary  artery,     c,  Secondary  artery. 


surface  of  the  gland.  One  branch,  which  is  constant  and 
larger  than  the  others,  he  designates  as  the  principal  artery  of 
the  mamma.  There  are  two  distinct  types  of  this  vessel,  as 
shown  in  figures  3  and  4.  This  vessel  gives  off  five  or  six 
branches  of  considerable  size,  as  well  as  a  number  of  smaller 
ones  which  anastomose  with  one  another  to  form  the  plexus 
above  mentioned.     Some  small  branches  from  this  plexus  are 


Anatomy  and  Physiology.  7 

transmitted  to  the  interior  of  the  gland,  although  they  do  not 
penetrate  it  deeply. 

The  external  mammary,  or  long  thoracic,  sends  a  few  branches 
around  the  lower  border  of  the  great  pectoral  muscle  just  be- 
fore it  terminates  in  the  intercostal  muscles.  One  of  these 
generally  passes  to  the  superficial  fascia  and  anastomoses  with 
the  vessels  of  the  anterior  superficial  plexus. 

The  superior  thoracic  sometimes  sends  a  few  branches  to  the 
upper  external  quadrant  of  the  breast. 


Artery  of  the  nipple 


External  branch 


Fig.  5. — Arteries  of  the  areola;  posterior  aspect. 
(Adapted  from  Piet.) 

The  pectoral  branch  of  the  acromio-thoracic,  sometimes 
incorrectly  called  the  short  thoracic  (a  term  which  is  liable  to 
lead  to  its  confusion  with  the  superior  thoracic,  the  first  branch 
of  the  axillary),  sends  one  or  more  branches  outwards  through 
the  pectoralis  major  to  the  mamma  as  it  pursues  its  course 
between  this  muscle  and  the  pectoralis  minor. 

The  branches  from  the  intercostals  perforate  the  great  pec- 
toral, pass  vertically  downward  between  this  muscle  and  the 
posterior  surface  of  the  gland  for  a  distance  of  two  or  three 


8 


Diseases  of  the  Breast. 


centimeters,  and  then  perforate  the  gland  to  be  distributed  to  its 
deep  lobes.  Some'of  them  probably  anastomose  with  branches 
from  the  superficial  portion  of  the  gland,  although  Piet  found  it 
difficult  to  inject  them  through  the  principal  branch  of  the 
internal  mammary. 
From  thejanterior  plexus  four  or  five  branches  are  given  off 


Fig.  6. — Veins  on  the  anterior  surface  of  the  mammary  gland. 
{Adapted  jrom  Piet.) 

to  supply  the  nipple  and  areola.  Each  of  these  divides  again 
into  two  branches,  an  anterior  and  a  posterior,  the  former  of 
which  anastomose  to  form  a  small  subplexus  and  then  pass  to 
the  extremity  of  the  nipple.  The  posterior  branches  are  dis- 
tributed beneath  the  areola. 
The  veins  correspond  in  general  to  the  arteries,  being  super- 


Anatomy  and  Physiology.  9 

ficial  and  deep;  the  former  set  are  likewise  the  most  important. 
There  is  a  principal  vein  corresponding  to  the  principal  artery, 
and  also  not  uncommonly  a  second  one  of  equal  size  which  fol- 
lows the  course  of  the  chief  lymphatic  channel  and  empties 
into  the  axillary  vein.  The  principal  vein  is  a  tributary  of  the 
internal  mammary. 


Fig.  7. 


-Veins  on  the  anterior  surface  of  the  breast. 
{Adapted  from  Piet.) 


In  addition  to  these  there  are  five  or  six  smaller  veins  which 
originate  in  the  subcutaneous  plexus  and  empty  into  the  inter- 
nal and  external  mammary,  the  subclavian,  and  the  intercostal 
veins  respectively. 

There  is  an  anastomosis  of  veins  around  the  nipple  which  is 
known  as  the  circle  of  Haller. 

The  deep  veins  of  the  mammary  gland  are  small  and  few  in 


io  Diseases  of  the   Breast. 

number  in  comparison  with  those  over  the  superficial  portion. 
They  anastomose  by  minute  twigs  with  the  superficial  vein-. 

Thus  it  is  seen  that  the  principal  blood  supply  of  the  gland, 
both  arterial  and  venous,  is  superficial.  This  fact  has  a 
practical  application  in  the  surgery  of  the  gland  and  will  be 
referred  to  again  when  the  operation  of  plastic  resection  of  the 
breast  for  benign  growths  and  cysts  is  considered. 

Lymphatics. — The  mammary  gland  is  drained  by  a  com- 
plex lymphatic  system,  which  is  much  more  intricate  and  exten- 
sive than  it  was  formerly  thought  to  be.  The  lymphatic  ves- 
sels may  be  divided  into  a  cutaneous  and  a  glandular  group, 
the  latter  being  subdivided  into  principal  and  accessory  channels. 

The  cutaneous  vessels  may  be  conveniently  considered  in 
two  groups,  namely,  those  over  the  periphery  and  those  over 
the  center  of  the  gland.  The  former  communicate  with  the 
vessels  of  the  opposite  breast,  a  fact  which  may  explain  the  oc- 
currence of  infection  in  the  second  breast  when  one  is  diseased. 
Poirier  and  Cuneo  have  recently  described  a  distinct  set  of  ves- 
sels which  drains  the  upper  part  of  the  breast  and  passes  directly 
over  the  clavicle  to  empty  into  the  supraclavicular  glands. 
The  central  set  form  an  intricate  network  around  the  nipple 
and  areola  which  sends  branches  inward  to  unite  with  others 
from  the  substance  of  the  gland  and  form  the  subareolar  plexus. 

The  principal  lymphatic  channel,  the  only  one  described  by 
Sappey,  originates  in  the  perilobular  sacs,  being  formed  by  the 
confluence  of  minute  channels  which  pass  between  the  galac- 
tophorous  ducts  towards  the  nipple  and  terminate  in  the  sub- 
areolar plexus.  From  this  plexus  two  trunks  are  given  off,  an 
internal  and  an  external,  both  of  which  empty  into  a  few  glands 
on  the  internal  wall  of  the  axilla,  at  its  upper  portion.  The  ex- 
ternal channel,  the  smaller  of  the  two,  passes  directly  outwards 
from  the  breast  to  the  axilla,  receiving  in  its  course  a  tributary 
from  the  superior  portion  of  the  gland.  The  internal  channel 
passes  downwards  and  outwards  along  the  lower  border  of  the 


Anatomy  and  Physiology.  n 

pectoralis  major  muscle,  which  it  crosses  at  about  the  level  of 
the  third  rib  to  proceed  outward  and  enter  the  axilla,  where  it 
empties  into  the  glands  already  named. 

In  addition  to  this  principal  channel,  three  accessory  chan- 
nels are  recognized  by  Poirier  and  Cuneo.  These  are  the 
internal  mammary,  the  subclavian,  and  the  axillary.  The 
internal  mammary  is  formed  by  the  confluence  of  trunks 
arising  from  the  inner  extremity  of  the  mamma;  after  perfor- 
ating the  greater  pectoral  and  internal  intercostal  muscles  it 
empties  into  the  glands  of  the  mammary  chain.  The  subcla- 
vian channel  is  given  off  from  the  posterior  surface  of  the 
mamma,  and  after  perforating  the  pectoralis  major  runs  be- 
tween this  muscle  and  the  pectoralis  minor  to  empty  into  the 
subclavian  glands.  There  are  several  small  glands  along  the 
course  of  this  channel  which,  according  to  Rotter,  are  enlarged 
in  one-half  of  all  cases  of  cancer.  The  accessory  axillary 
channel  begins  at  the  inferior  portion  of  the  gland  by  a  few 
small  vessels  and  passes  directly  to  the  axilla. 

Still  another  accessory  channel  has  been  observed  by  Oelsner. 
This  investigator  has  found  several  small  channels  at  the 
inferior  border  of  the  gland  which  traverse  the  great  pectoral 
muscle  and  then  pass  into  the  thorax  through  the  fourth  inter- 
costal space.  Some  of  these  branches  follow  the  intercostal 
vessels  to  the  spine,  a  circumstance  which  explains  those  cases 
of  mammary  cancer  which  are  ultimately  complicated  with 
spinal  symptoms,  or  even  paraplegia. 

In  order  thoroughly  to  understand  the  possibilities  of  car- 
cinomatous dissemination  through  the  lymphatic  system,  it  is 
necessary  to  understand  not  only  the  drainage  of  the  mammary 
gland  by  its  principal  and  accessory  large  channels,  but  also  to 
possess  an  adequate  conception  of  the  arrangement  and  dis- 
tribution of  the  fascial  lymphatic  plexus.  Mr.  Handley's 
description  of  this  great  lymphatic  investment  of  the  body  is  so 
lucid  and  concise  that  I  cannot  do  better  than  quote  it. 


12 


Diseases  of  the   Breast. 


"This  great  plexus  is  divisible  by  the  median  plane  of  the 
body  and  by  two  horizontal  planes  passing  through  the  clavicle 
and  through  the  umbilicus  respectively,  into  six  catchment 
areas,  three  on  either  side,  draining  as  the  case  may  be  into 
the  cervical,  the  axillary,  or  the  inguinal  glands.  The  line, 
or  rather  zone,  separating  any  two  adjacent  areas,  may  be  called 
the  lymphatic  water-parting,  and  is  anatomically  a  zone  of  nar- 


FlG.  8. — Lymphatic  vessels  of  the  anterior  surface  of  the  breast ;  the  subareolar 
plexus  and  the  trunks  which  run  from  it  (Sappey).  i,  i.  Lymphatic  network  of 
the  anterior  surface  of  the  mammary  gland.  2,  2.  Lobules  of  the  gland,  the 
peripheral  network  of  which  has  not  been  injected  in  order  that  the  circumlob- 
ular  network  which  encircles  it  may  be  seen.  3,  3,  3,  3.  Trunks  which  arise 
from  the  upper  and  lower  parts  of  the  gland.  4,  4.  Subareolar  lymphatic  plexus. 
5.  Lymphatic  vessel  which  arises  from  the  inner  part  of  this  plexus.  6.  Vessel 
arising  from  the  inner  part  of  the  same  plexus.  7.  Vessel  coming  from  the  lower 
part  of  the  gland;  after  a  long  course  it  unites  with  the  preceding  to  form  one  of 
two  trunks  in  which  all  the  others  end.  8,  8.  The  two  principal  lymphatic  trunks 
which  extend  transversely  from  the  mamma  to  the  axillary  glands.  ("The 
Lymphatics,"  C.  H.  Lea}.) 

row  tortuous  channels,  nowhere  traversed  by  trunk  lymphatics, 
a  region,  consequently,  where  the  lymph  stream  is  at  its  feeblest, 
and  where  even  very  fine  particles  are  liable  to  be  arrested. 

"The  general  idea  then,  which  we  have  obtained  of  the  pari- 
etal lymphatic  system  is  that  of  a  vast  horizontal  network  of 
fine  channels,  co-extensive  with  the  surface  of  the  body,  and  re- 


Anatomy  and   Physiology. 


13 


ceiving  above  numberless  fine  vertical  tributaries,  which  con- 
vey to  it  the  lymph  from  the  skin  and  its  appendages.  Among 
the  latter  we  must  include  the  breast.  On  its  deep  aspect  the 
plexus  receives  tributaries  from  the  subjacent  tissues.     From 


■:%:  r\m 


Fig.  9. — Lymphatic  vessels  of  the  antero-lateral  portions  of  the  thorax 
(Sappey).  1,  1.  Axillary  glands.  2,  2.  Superficial  lymphatic  trunks  of  the 
upper  limb.  3,  3.  Large  trunks  which  also  come  from  the  integuments  of  the 
upper  limb,  but  which  instead  of  ending  in  the  glands  of  the  axilla,  run  in  the 
space  between  the  deltoid  and  pectoralis  major,  and  terminate  in  a  subclavicu- 
lar gland.  4.  A  gland  which  is  sometimes  seen  in  the  course  of  this  trunk. 
5,  5.  Lymphatic  vessels  of  the  anterior  superior  part  of  the  thorax.  6,  6,  7,  7. 
Lymphatic  vessels  which  start  from  the  integuments  of  the  thorax.  ("  The 
Lymphatics,"  C.  H.  Leaf.) 


this  great  plexus,  which  lies  in  the  subcutaneous  fat  upon  the 
deep  fascia,  the  lymph  is  conveyed  by  six  sets  of  lymphatic 
trunks,  each  draining  a  definite  area,  to  the  cervical,  the 
axillary,  or  the  inguinal  glands." 

Nerves. — The  nerves  of  the  mammary  gland  are  derived 


14  Diseases  of  the   Breast. 

from  the  intercostals,  from  the  supraclavicular  branch  of  the 
cervical  plexus,  and  from  thoracic  branches  of  the  brachial 
plexus.  They  are  distributed  to  the  skin  over  the  gland,  to  the 
muscular  fibers  of  the  areola,  to  the  blood-vessels,  and  to  the 
glandular  substance  itself. 

Variations  from  the  Normal. — There  may  be  either  a  re- 
duction or  an  augmentation  in  the  number  of  the  breasts.  To 
the  former  condition  the  term  amazia  is  applied,  to  the  latter, 
polymastia. 

Congenital  absence  of  both  breasts  is  exceedingly  rare,  and 
unilateral  absence  is  by  no  means  common. 

Absence  of  the  nipple  is  another  abnormality  which  requires 
mention.  To  this  condition  the  term  athelia  is  applied.  When 
it  exists  the  galactophorous  ducts  make  their  exit  at  the  center 
of  the  areola,  usually  in  a  slight  depression  occupying  the  site 
of  the  nipple. 

Increase  in  the  number  of  breasts,  or  polymastia,  is  much 
more  common  than  amazia.  Polythelia,  or  the  presence  of 
more  than  one  nipple,  is  also  comparatively  frequent.  The 
supernumerary  nipple  may  be  situated  on  the  areola,  close  to 
the  normal  nipple,  or  it  may  be  located  some  distance  away 
from  this  part  of  the  breast. 

In  regard  to  the  supernumerary  breasts,  their  size  and  loca- 
tion is  most  variable.  It  is  interesting  to  note,  however,  that 
they  are  most  commonly  found  on  those  portions  of  the  body 
where  breasts  normally  occur  in  certain  animals.  Thus  they 
are  often  found  in  the  axilla  or  upon  the  borders  above  or  below 
the  normal  breast,  on  the  lower  portion  of  the  thoracic  wall, 
and  also  on  the  abdominal  wall.  Their  occurrence  on  the 
abdomen,  however,  is  much  rarer  than  on  the  portion  of  the 
body  previously  named. 

They  have  also  been  found  on  the  back,  the  shoulders,  and 
various  parts  of  the  thigh. 

As  regards  their  numerical  occurrence,  not  more  than  one  or 


Anatomy  and  Physiology.  15 

two  are  present,  as  a  rule,  although  three  sometimes  occur,  and 
there  are  isolated  cases  on  record  in  which  six  or  eight  have 
been  present.  In  most  cases  probably  there  is  only  one. 
Polymastia  occurs  in  men  as  well  as  women,  and  by  some 
anatomists  has  been  considered  equally  as  common  among 
them  as  among  the  latter  sex.  Recent  statistics,  however, 
show  that  it  is  more  frequent  among  women.     Of  two  hundred 


Fig.  10. — Lymphatics  of  the  breast  and  axillary  glands  (semidiagrammatic). 
1.  Delto-pectoral  gland.  2,  2.  Glands  of  the  humeral  chain.  3,  3.  Glands  of 
the  central  group  and  the  scapular  chain.  4,  4.  Glands  of  the  thoracic  chain 
(supero-internal  group).  5.  Gland  of  the  thoracic  chain  (infero-external  group). 
6.  Subclavian  glands.  7.  Mammary  lymphatic  ending  in  the  subclavian  glands 
(inconstant).  8,  9.  Mammary  collecting  trunks,  ending  in  glands  of  the  thoracic^ 
chain.  10.  Subareolar  plexus,  n.  Cutaneous  collecting  trunk  of  the  lateral' 
walls  of  the  thorax.  12,  13.  Mammary  collecting  trunks  about  to  end  in  the  in- 
ternal mammary  glands.     ("  The  Lymphatics,"  C.  H.  Leaf.) 

and  sixty-two  cases  collected  by  Hanseman  only  a  small  per- 
centage were  in  men. 

Heredity  is  supposed  to  play  a  role  in  its  occurrence.  These 
breasts  are  seldom  functionally  perfect. 

The  Male  Breast. — In  the  adult  male  the  mammary  gland 
is  perfectly  developed.  At  birth,  however,  it  is  of  about  the 
same  dimensions  as  in  the  female.  At  puberty  signs  of  evolution 
sometimes  appear,  the  gland  enlarging  somewhat  and  becoming 


i6  Diseases  of  the   Breast. 

slightly  painful.  These  signs  of  activity  soon  subside  and  the 
gland  returns  to  its  original  size. 

Its  structure  is  practically  the  same  as  that  of  the  female 
organ  with  the  exception  that  a  typical  areola  is  not  found. 
The  galactophorous  ducts  are  also  rudimentary. 

Physiologically  the  breast  is  a  secreting  organ  appurtenant 
to    the    reproductive  system,   and  characterized  particularly 


Fig.  ii. — Scheme  of  the  axillary  glands.  2.  Supraclavicular  glands,  b.  Sub- 
clavian glands,  c.  Humeral  chain,  d.  Scapular  chain,  e.  Infero-external 
portion  of  the  thoracic  chain.  /.  Supero-internal  portion  of  the  thoracic  chain. 
g.  Central  group.  The  dark  dotted  line  indicates  the  situation  of  the  clvicale. 
("  The  Lymphatics,"  C.  H.  Leaf.) 

by  periodical  phases  of  activity,  which  are  most  pronounced 
during  the  era  of  active  sexual  life. 

The  secreting  power  of  the  gland,  however,  often  manifests 
itself  shortly  after  birth,  inasmuch  as  a  small  quantity  of  milk 
is  discharged  from  the  nipple. 

That  this  secretion  is  a  true  lactation  has  been  proved  by 
De  Sinety  (Arch,  de  Physiologie,  1875)  an<^  a^s0  by  Variot, 
Kolliker,  Barfurth  and  others. 

This  activity  soon  subsides,  as  a  rule,  and  the  gland  remains 
quiescent    until   puberty,   when   its  dormant   vitality   is   first 


Anatomy  and  Physiology.  17 

markedly  aroused  and  it  undergoes  a  series  of  changes  in  com- 
mon with  the  other  organs  constituting  the  reproductive 
system. 

A  few  cases  of  persistent  lactation  in  the  new-born  have 
been  recorded.  Thus  Mr.  Sheild  mentions  one  occurring  in  a 
female  child  aged  sixteen  days.  A  more  remarkable  case  is 
one  recently  reported  by  Mr.  Murray  (Lancet,  Jan.  7,  1905) 
occurring  in  a  male  child  aged  three  and  one-half  months. 
Both  breasts,  which  were  enlarged  to  about  the  size  of  a  billiard 
ball,  were  firm  with  palpable  gland  substance ;  the  nipples  were 
also  enlarged  and  oozed  fluid  resembling  milk.  The  mother 
said  the  child's  breasts  began  to  enlarge  when  he  was  five 
weeks  old,  and  had  gradually  increased  in  size.  The  child 
died  from  congenital  heart  disease  three  weeks  after  admission 
to  the  Hospital.  Section  showed  both  breasts  to  be  lactating. 
The  gland  substance  was  healthy,  the  ducts  enlarged  and  irregu- 
lar. Microscopically  the  secretion  resembled  milk,  although 
the  fat  content  appeared  low. 

At  puberty  there  is  a  rapid  growth  of  the  organ,  which  soon 
attains  the  normal  size,  form  and  consistence  that  characterizes 
it  in  the  adult  female  who  has  never  borne  children.  It  does 
not  reach  its  highest  degree  of  development  until  pregnancy, 
parturition  and  lactation  have  taken  place.  Thus,  although 
the  increase  in  the  size  of  the  breast  occurring  at  puberty  is 
accompanied  by  formation  and  partial  development  of  alveoli, 
which  are  the  physiological  units  of  the  organ,  these  structures 
are  not  completely  developed  until  the  first  pregnancy  has 
terminated  and  lactation  begun.  At  puberty  they  develop 
only  at  the  periphery  of  the  gland. 

The  structural  transformation  which  the  breast  undergoes 
at  puberty  is  accompanied  by  manifestations  of  functional 
awakening;  and  just  here  it  may  not  be  amiss  to  state  that  struc- 
ture and  function  are  inseparably  connected,  that  when  the 
potential  specific  activity  existing  in  the  organ  from  the  estab- 


18  Diseases  of  the   Breast. 

lishment  of  puberty  to  the  incidence  of  the  climacteric  becomes 
actually  manifest,  certain  alterations  in  the  structure  of  the 
alveoli,  the  physiological  units,  are  observed  to  take  place. 
These  are  particularly  marked  during  the  period  of  lactation, 
and  will  be  described  in  detail  when  this  subject  is  discussed. 

In  reference  to  the  functional  manifestations  which  occur 
at  puberty,  it  has  been  observed  that  pain  is  frequently  com- 
plained of,  that  the  breasts  are  tender  to  touch,  and  that  slight 
swelling  of  the  lymphatic  glands  which  receive  the  lymph  from 
the  mamma  sometimes  occurs.  , 

After  the  establishment  of  puberty  the  gland  becomes  quies- 
cent until  pregnancy  occurs,  when  it  undergoes  decided  changes. 
At  about  the  eighth  week  after  conception  the  breasts  begin  to 
increase  in  size  and  continue  to  enlarge  until  the  termination 
of  pregnancy,  and  for  some  days  thereafter.  There  is  an  increase 
in  all  the  constituent  structures.  The  alveoli  become  larger 
and  more  numerous,  the  blood-vessels  distended,  the  superfi- 
cial veins  prominent,  the  areola  larger  and  darker  in  color,  and 
the  nipples  swollen  and  sore.  The  secondary  areola  is  also 
formed  at  this  time.  The  tubercles  of  Montgomery  enlarge, 
and  striae  form  in  the  skin  owing  to  the  pressure  exerted  upon 
it  by  the  distended  gland. 

If  the  alveoli  be  examined  microscopically  at  this  period, 
it  will  be  found  that  they  are  in  reality  solid  cylinders  composed 
of  cells.  Toward  the  close  of  pregnancy,  or  soon  after  delivery, 
some  of  these  cells  are  cast  off,  leaving  a  single  mosaic  layer 
to  line  the  walls  of  the  alveoli. 

All  these  changes  are  wrought  in  anticipation  of  and  prep- 
aration for  the  specific  function  of  lactation,  which  begins 
shortly  after  the  occurrence  of  parturition. 

For  the  first  day  or  two  after  delivery  the  breasts  secrete  a 
substance  known  as  colostrum,  a  yellowish-white  fluid  contain- 
ing cast  off  cells  which  have  undergone  fatty  degeneration  and 
which  are  known   as  colostrum  corpuscles.     It  is  supposed 


PLATE  I. 


Section  from  a  non-lactating  breast. 


Anatomy  and   Physiology.  21 

that  these  cells  are  derived  from  the  interior  of  the  alveoli,  that 
they  do  not  possess  the  secreting  power  peculiar  to  those  which 
line  the  alveolar  walls  and  that  they  are  therefore  cast  off.  The 
destruction  of  these  cells  creates  a  lumen  within  the  alveoli 
which  was  not  present  during  pregnancy.  Thus  recepta*  les 
are  formed  for  the  milk  before  it  begins  to  be  secreted. 

The  fluid  portion  of  the  colostrum  is  merely  a  serous  trans- 
udate and  in  no  wise  a  specific  secretion  of  the  mammary  gland. 

Usually  on  the  second  or  third  day  after  delivery  milk  begins 
to  be  secreted.  Its  appearance  is  not  uncommonly  accompanied 
by  slight  local  and  constitutional  disturbances,  which  are  the 
expression  of  the  increased  cellular  metabolism  upon  which 
the  production  of  the  milk  depends.  Thus  slight  elevation 
of  temperature,  as  well  as  soreness  and  swelling  of  the 
breasts,  sometimes  occurs.  Enlargement  of  the  lymphatic 
glands  in  the  axilla  and  above  the  clavicle  has  also  been  known 
to  take  place.  These  changes  are  due  entirely  to  increased 
functional  activity  of  the  gland,  and  not  to  any  extraneous 
causes.  Perhaps  it  may  be  absorption  of  waste-products  of 
the  cells,  products  which  are  elaborated  and  cast  off  as  the 
result  of  the  increased  work  going  on  in  the  gland,  that  produces 
these  phenomena. 

That  the  secretion  of  milk  is  governed  by  the  nervous  system  is 
shown  by  experimentation  and  clinical  observation.  Although 
the  results  of  the  former  are  not  entirely  in  accord,  enough 
has  been  demonstrated  to  show  that  there  is  a  decided  nervous 
influence  presiding  over  the  function  of  lactation.  Stimula- 
tion of  the  mammary  nerve  in  a  bitch  was  followed  by  secretion 
of  milk  (Laffont).  Irritation  of  the  sensory  nerves  in  the  nip- 
ple also  results  in  a  more  profuse  flow  of  milk.  Thus  it  is 
well-known  among  parturient  women  that  putting  the  child  to 
the  breast  stimulates  the  secretory  power  of  the  gland.  Remark- 
able cases  have  been  reported  in  which  the  male  breast  was 
stimulated  to  secretion  in  this  manner. 


22  Diseases  of  the   Breast. 

The  influence  of  fright  and  anxiety  is  well-known ;  it  is  not  at 
all  unusual  for  complete  temporary  arrest  of  secretion  to  occur 
in  women  who  are  subject  to  either  of  these  emotions. 

We  have  already  seen  that  the  mammary  gland  develops 
simultaneously  with  the  organs  properly  constituting  the  repro- 
ductive system.  Its  intimate  relation  with  these  organs  is 
again  manifested  not  only  during  pregnancy,  when  it  attains 
a  high  degree  of  development,  but  also  during  the  period  of  lac- 
tation. Thus  it  has  been  observed  that  the  uterus  sometimes 
fails  to  undergo  normal  involution  when  milk  fails  to  be  secreted, 
a  circumstance  which  may  be  attributed  to  the  absence  of 
uterine  contractions  produced  by  the  stimulation  of  suckling. 

If  now  we  come  to  study  the  alveoli,  the  functionating  por- 
tion of  the  breast,  during  the  period  of  lactation,  not  only  will 
their  condition  be  found  different  than  it  is  before  and  during 
pregnancy,  but  variations  will  be  observed  according  as  they 
are  examined  when  actively  functionating  or  at  rest.  To  these 
conditions  Michael  Foster  has  applied  the  terms  loaded  phase 
and  discharged  phase  respectively.  He  describes  them  as 
follows : 

"In  the  discharged  phase  the  alveolus  is  lined  by  a  layer  of 
low  cubical  or  even  flattened  cells,  so  that  the  relatively  large 
area  of  the  alveolus  is  almost  wholly  occupied  by  the  lumen 
in  which  some  of  the  constituents  of  the  milk  may  still  be 
retained.  Each  cell  consists  of  granular  cell-substance  in 
which  is  placed  a  rounded  or  oval  nucleus;  sometimes  the  free 
edge  of  the  cell  is  jagged  and  uneven  as  if  a  portion  of  the  bor- 
der had  been  torn  away. 

"In  a  fully  loaded  phase  the  appearances  are  very  different. 
The  alveolus  is  now  lined  with  a  layer  of  tall  columnar  cells 
projecting  unevenly  into  the  lumen,  the  outline  of  which 
is  correspondingly  irregular  and  the  area  of  which  is  much 
reduced.  While  the  broader  base  of  each  cell  rests  on  the  base- 
ment membrane,  the  other  end,  the  conical  or  irregular,  stretches 


PLATE  II. 


Section  from  a  lactating  breast. 


Anatomy  and  Physiology.  25 

towards  the  center  of  the  lumen.  Instead  of  one  nucleus  two 
or  more  are  now  present,  one,  well-formed  and  normal,  being 
placed  near  the  base,  and  the  others,  often  showing  signs  of 
breaking  up  or  degeneration,  nearer  the  free  end.  Some  of 
the  cell,  including  one  or  more  of  the  nuclei,  is  apparently 
being  separated  from  the  basal  portion  in  which  the  remaining 
nucleus  is  lodged,  and  occasionally  portions  or  fragments  of 
cells,  nucleated  or  nucleusless,  may  be  seen  lying  in  the  cavity 
of  the  alveolus.  In  the  cell-substance,  especially  toward  the 
free  border  of  the  cell,  are  numerous  oil-globules  of  various 
sizes,  as  well  as  granules  or  particles  of  other  nature;  some 
of  the  larger  oil-globules  may  be  seen  projecting  from  the 
surface  as  if  about  to  be  extruded  from  the  cell;  and  in  the 
cavity  of  the  alveolus  oil-globules  with  a  thinner  or  thicker 
coating  of  cell-substance  are  frequently  present. 

"Between  such  a  fully  loaded  phase,  and  a  completely  dis- 
charged phase,  various  intermediate  conditions  may  be  observed, 
the  cells  being  of  greater  or  less  height,  containing  one  nu- 
cleus only  or  more  than  one,  the  cell-substance  occupied  with 
few  or  many  oil-globules  and  other  granules,  and  the  free  border 
more  or  less  jagged." 

This  detailed  description  of  the  physiological  unit  of  the 
mamma  during  the  stage  of  its  greatest  activity  has  been  quoted 
in  order  better  to  contrast  the  condition  which  obtains  in  it 
during  the  subsidence  of  lactation  and  the  period  in  which  it 
is  restored  to  its  previous  condition.  The  microscopic  appear- 
ance of  the  non-lactating  and  lactating  breast  is  shown  in  Plates 
I  and  II  respectively. 

The  term  involution  is  applied  to  the  process  by  which  the 
breast  is  rehabilitated. 

If  a  section  of  the  mamma  be  examined  during  the  period  of 
involution,  the  alveoli  will  be  found  to  be  much  smaller  than 
they  were  during  lactation.  The  cells  lining  their  walls  are 
much  reduced  in  number  and  are  also  smaller  in  size,  and  their 


26  Diseases  of  the   Breast. 

protoplasm  has  disappeared,  leaving  the  nuclei  unsurrounded. 
As  the  process  of  involution  progresses  the  alveoli  become  con- 
verted into  spherical  spaces  containing  the  nuclei  of  the  cells 
which  lined  their  walls  during  the  period  of  lactation.  These 
contracted  alveoli  are  not  surrounded  by  minute  blood-vessels 
as  they  are  when  the  gland  is  at  the  height  of  its  activity,  al- 
though some  are  still  seen  ramifying  in  various  directions. 

The  contraction  of  the  alveoli  is  uniform  throughout  the 
lobule,  as  a  result  of  which  the  various  lobules  become  reduced 
in  size,  spaces  being  formed  between  them. 

In  addition  to  the  alterations  in  the  alveoli,  changes  also 
occur  in  the  other  portions  of  the  gland.  Thus  there  is  an 
increase  in  the  fibrous  tissue  between  the  lobules  and  in  the  fat 
surrounding  the  gland. 

When  another  pregnancy  occurs  the  same  process  of  evolu- 
tion previously  described  is  gone  through  and  the  functionating 
power  of  the  gland  again  raised  to  its  highest  degree  during  the 
ensuing  period  of  lactation. 

It  is  evident  that  these  phases  of  evolution  and  involution 
of  the  breast  are  accompanied  by  much  tissue  formation  and 
tissue  destruction,  and  it  is  not  unreasonable  to  suppose  that 
deviations  from  the  normal  method  of  metamorphosis  furnish 
a  basis  for  the  development  of  some  of  the  morbid  processes 
to  which  the  organ  is  subject.  Reference  to  this  matter  will 
be  made  again  when  considering  the  pathology  of  tumors. 

During  the  climacteric  the  mammary  gland  atrophies  and 
becomes  much  decreased  in  size. 


INFLAMMATORY  DISEASES  OF  THE  BREAST. 

Under  this  heading  will  be  considered  congestion  and  en- 
gorgement, acute  mastitis,  acute  abscess,  chronic  mastitis,  and 
chronic  abscess. 

With  the  exception  of  chronic  mastitis  these  affections  are 
most  common  in  the  puerperium,  and,  indeed,  engorgement  of 
the  milk-ducts  occurs  at  no  other  time. 

The  terms  congestion  and  engorgement  are  commonly  ap- 
plied to  the  same  condition,  namely,  distention  of  the  galactoph- 
orous  ducts  with  milk.  The  inflammation  or  congestion  of 
the  breast  occurring  in  the  new-born  and  at  puberty  has  already 
been  mentioned.  In  the  former  it  is  more  likely  to  develop 
if  attempts  are  made  to  press  the  secretion  out  through  the 
nipple. 

If  infection  takes  place,  as  not  uncommonly  happens,  sup- 
puration may  ensue. 

Usually  these  affections  are  readily  relieved  by  simple  hot 
applications.  Sometimes,  however,  suppuration  ensues  and 
then  incision  is  required.  The  subsequent  cicatrization  may 
interfere  with  the  development  of  the  breast.  The  pressure 
resulting  from  distention  of  the  breast  with  milk  gives  rise  to 
irritation  and  swelling  of  the  affected  parts,  which  most  com- 
monly are  the  lower  and  external  portions. 

These  local  manifestations  of  interference  with  the  normal 
function  of  lactation  are  accompanied  by  signs  of  constitutional 
disturbance  which,  however,  are  slight  unless  an  infective  process 
be  superimposed  upon  the  one  already  present.  Thus  a  slight 
rise  of  temperature  and  moderate  headache,  together  with  a 
general  feeling  of  ill-being,  are  not  infrequently  present. 

It  has  been  observed  that  the  incidence  of  this  affection  is 

27 


28  Diseases  of  the   Breast. 

most  common  on  the  third  or  fourth  day  after  delivery.  It 
may  occur  at  any  time,  however,  particularly  if  nursing  be  sud- 
denly interrupted,  as  for  example,  by  the  death  of  the  child, 
or  because  of  soreness  of  the  nipple  so  severe  as  to  prevent 
suckling. 

The  therapeutic  indications  are  to  empty  the  breasts,  relieve 
congestion,  and  afford  proper  support. 

They  are  met  by  gentle  massage,  properly  supporting  ban- 
dages, hot  moist  applications,  and  the  administration  of  saline 
cathartics. 

The  breast  may  be  gently  rubbed  with  warm  sterilized  olive- 
oil,  or  with  a  mixture  composed  of  lanoline  one  part  and  ben- 
zoated  lard  seven  parts,  the  mixture  being  liquefied  and  steril- 
ized in  a  water-bath  each  time  it  is  used.  The  use  of  a  fatty 
substance  in  conjunction  with  massage  seems  to  be  of  real 
benefit  as  well  as  being  decidedly  grateful  to  the  patient. 

Hot  moist  applications  may  be  used  in  the  intervals.  A 
flannel  wrung  out  of  hot  normal  saline  solution  or  a  saturated 
solution  of  boric  acid  may  be  applied  to  the  breast  and  covered 
with  oiled  silk,  being  changed  as  soon  as  it  begins  to  get  cold. 
Such  applications  may  be  kept  up  constantly  if  a  nurse  is  in 
attendance,  otherwise  they  are  to  be  made  for  periods  for  one- 
half  hour,  three  or  four  times  a  day. 

As  already  stated  properly  supporting  bandages  are  to  be 
applied.  As  the  engorgement  subsides  compression  may  be 
increased  by  putting  cotton  or  wool  beneath  the  bandage  and 
binding  it  firmly  to  the  skin. 

In  regard  to  the  purgatives  Epsom  or  Rochelle  salts  answer 
every  purpose. 

It  was  formerly  held  that  engorgement  of  the  breast  was  the 
cause  of  mastitis  and  abscess.  It  is  now  known,  however,  that 
such  is  not  the  case,  although  it  is  still  admitted  that  engorge- 
ment acts  as  a  predisposing  cause. 

The  essential  cause  of  inflammation  of  the  breast,  whether 


Inflammatory  Diseases  of  the  Breast.  29 

simple  or  suppurative,  is  infection  with  microorganisms,  prin- 
cipally the  staphylococcus  pyogenes  aureus.  Streptococcic 
infection  may  also  occur,  and  is  of  a  particularly  virulent  form, 
giving  rise  to  suppuration  and  severe  constitutional  disturb- 
ances. 

Infection  usually,  though  not  always,  takes  place  through  an 
abrasion  on  the  nipple,  areola,  or  skin  on  some  other  portion  of 
the  breast. 

It  is  theoretically  possible,  and  no  doubt  sometimes  actually 
happens,  that  germs  already  present  in  the  gland  are  aroused 
to  renewed  activity  during  the  period  of  lactation,  with  the  re- 
sult that  inflammatory  processes  are  lighted  up.  It  is  evident 
that  the  congestion  incident  to  engorgement  of  the  gland  would 
afford  a  favorable  soil  for  the  growth  of  any  organisms  pres- 
ent, for  example,  those  left  dormant  after  the  subsidence  of  a 
previous  attack  of  suppurative  inflammation. 

The  occurrence  of  mammary  abscesses  during  the  course  of 
pyemia  or  as  a  complication  or  sequel  of  erysipelas  furnishes  a 
good  example  of  infection  by  way  of  the  blood  current. 

In  the  vast  majority  of  instances,  however,  careful  examina- 
tion will  reveal  a  solution  of  continuity  in  some  part  of  the  in- 
tegument, usually  on  that  covering  the  nipple  or  areola. 

The  infection  may  be  conveyed  through  the  mouth  of  the 
child,  by  the  hands  of  a  dirty  nurse  or  a  careless  physician, 
or  by  the  mother  herself. 

Three  varieties  of  inflammation  are  distinguished,  namely, 
superficial  or  subcutaneous,  deep  or  parenchymatous,  and 
retromammary. 

In  the  superficial  form  the  infective  microorganisms  are 
conveyed  by  the  lymphatics  to  the  tissues  just  beneath  the 
areola,  or  occasionally  for  a  short  distance  beyond,  where  they 
set  up  an  inflammatory  process.  The  affected  area  becomes 
reddened,  sore,  and  swollen. 

The  inflammation  is  prone  to  extend  superficially,  especially 


30  Diseases  of  the  Breast. 

if  it  goes  on  to  suppuration,  advancing  towards  the  skin  rather 
than  laterally.  This  circumstance  is  due  to  the  fact  that  lat- 
eral extension  is  limited  by  the  superficial  processes  of  fibrous 
tissue  extending  from  the  interlobular  septa  to  the  skin. 

It  may,  however,  invade  the  deeper  portions  of  the  gland, 
extending  along  the  interlobular  septa  and  thus  giving  rise  to 
the  parenchymatous  form.     The  septa  between  contiguous 


Fig.  12. — Acute  mastitis. 

lobules  may  be  broken  down  and  the  breast  become  honey- 
combed, or  the  pus  may  extend  along  an  interlobular  septum 
to  the  tissues  behind  the  gland  and  lead  to  the  formation  of  a 
retromammary  abscess.  In  the  latter  instance  a  considerable 
accumulation  of  pus  may  result,  so  that  the  breast  becomes 
elevated  and  pushed  forward  from  the  thoracic  wall.  The 
pus  may  even  work  its  way  into  the  axilla,  extending  along  the 


Inflammatory  Diseases  of  the   Breast.  31 

anterior  border  of  the  pectoralis  major  muscle  and  perforating 
the  dense  fascia  forming  the  floor  of  this  space.  There  is  almost 
always  enlargement  of  the  axillary  glands  even  though  the  sup- 
purative process  itself  does  not  invade  the  axilla.  Difficulty 
in  moving  the  arm  is  also  experienced.  The  pain,  which  is 
most  severe,  is  deep  seated,  owing  to  the  location  of  the  morbid 
process;  it  also  gains  some  of  its  intensity  no  doubt  from  the 
resistance  to  its  extension  offered  by  the  surrounding  structures. 

Thus  the  absorption  of  pus  is  increased,  with  the  result  that 
the  manifestations  of  sepsis  are  intensified. 

Finally,  in  this  form  of  the  disease,  it  is  noteworthy  that  the 
skin  over  the  anterior  surface  of  the  breast  is  not  reddened  as 
it  is  in  the  superficial  and  parenchymatous  forms. 

These  retromammary  abscesses  are  not  very  common. 

In  regard  to  the  symptoms  and  signs  of  mastitis,  it  has  already 
been  stated  that  superficial  infection  produces  redness,  swelling 
and  soreness  of  the  affected  parts.  There  is,  moreover,  slight 
constitutional  disturbance. 

If  the  morbid  process  is  not  arrested  in  this  stage,  but  ad- 
vances to  suppuration,  both  local  and  constitutional  phenomena 
become  greatly  intensified.  The  swelling  of  the  breast  in- 
creases, great  discoloration  of  the  part  takes  place,  and  as 
destruction  of  tissue  goes  on  and  one  or  more  areas  of  fluctuation 
form,  violent  throbbing  pain,  chills  and  fever,  and  a  greater  or 
less  degree  of  prostration  are  experienced.  The  pulse  becomes 
accelerated,  the  tongue  coated,  and  the  skin  hot  and  dry. 
Profuse  sweats  sometimes  break  out.  In  a  word,  the  clinical 
picture  is  one  of  septic  infection,  presenting  different  degrees 
of  intensity  in  accordance  with  the  virulence  of  the  infecting 
microorganisms  and  the  extent  of  the  destructive  process  which 
they  produce. 

Streptococcic  infection  is  most  severe,  causing  all  the  symp- 
toms and  signs  of  acute  sepsis. 

The  diagnosis  is  not  difficult  as  a  rule,  although  in  the  early 


32  Diseases  of  the  Breast. 

stages  of  parenchymatous  mastitis  it  is  difficult  or  even  may  be 
impossible  to  determine  whether  pus  has  formed.  As  the 
process  advances,  however,  all  doubt  will  be  dispelled.  Both 
the  local  and  constitutional  manifestations  above  mentioned 
will  become  so  pronounced  as  to  make  the  nature  of  the  trouble 
clear.     Fluctuation  is  the  crucial  test. 

In  superficial  abscess  or  suppuration  of  the  glands  of  Mont- 
gomery the  diagnosis  is  readily  made. 

Retromammary  abscess  will  be  recognized  by  the  symptoms 
and  signs  already  enumerated. 

Treatment. — The  treatment  varies  according  as  the  case 
is  seen  before  or  after  suppuration  has  occurred. 

Prophylaxis  is  of  the  utmost  importance,  and  will  be  discussed 
before  treatment  is  considered. 

If  scrupulous  cleanliness  of  the  nipple  and  breast  is  observed 
before  and  especially  during  lactation,  if  measures  be  taken  to 
prevent  the  formation  of  fissures  of  the  nipple,  and  prompt 
and  careful  treatment  given  to  any  which  may  form  despite 
the  precautions  employed,  the  occurrence  of  mastitis  and  mam- 
mary abscess  can  be  much  diminished. 

During  pregnancy  small  retracted  nipples  should  be  regularly 
drawn  out,  although  great  gentleness  must  be  employed  in  this 
manipulation,  as  otherwise  injury  may  be  inflicted  and  thus  the 
very  danger  we  are  trying  to  obviate  be  increased. 

Any  abrasions  or  fissures  which  may  be  detected  should  be 
promptly  treated  by  healing  or  slightly  astringent  applications, 
such  as  boric  acid  ointment  or  weak  glycerite  of  tannin. 

After  labor  it  is  well  to  wash  the  breasts  and  nipples  with 
castile  soap  and  warm  sterilized  water,  and  then  apply  a  satur- 
ated solution  of  boric  acid.  The  use  of  bichloride  of  mercury 
solution  does  not  seem  necessary  to  me,  although  it  has  been 
recommended  by  many  competent  obstetricians. 

A  proper  supporting  bandage  should  also  be  applied  to  the 
breasts  for  the  purpose  of  preventing  engorgement. 


Inflammatory  Diseases  of  the  Breast.  33 

Each  time  before  the  child  is  put  to  the  breast  its  mouth 
should  be  gently  washed  with  the  saturated  solution  of  boric 
acid,  and  the  nipple  should  be  cleansed  with  the  same  solu- 
tion both  before  and  after  nursing.  If  the  nipple  becomes 
sore  despite  these  precautions,  a  shield  should  be  used  and  the 
antiseptic  wash  continued.  Oftentimes  an  ointment  composed 
of  boric  acid,  15  grains;  lanoline,  two  drams;  and  benzoated 
lard,  six  drams,  will  heal  abrasions  and  beginning  fissures.  The 
breast-pump  must  be  used  if  nursing  is  so  painful  as  to  be  intol- 
erable. 

The  treatment  of  mastitis  itself  consists  in  the  application 
of  evaporating  solutions,  such  as  lead-water  and  laudanum  or 
a  two  percent  solution  aluminum  acetate;  the  maintenance  of 
proper  support;  free  purgation  with  saline  cathartics,  and  the 
discontinuation  of  nursing.  Ice  applied  to  the  inflamed  parts 
is  often  of  benefit,  but  patients  very  commonly  complain  of  its 
being  painful.  The  breast-pump  is  to  be  used  when  nursing 
is  stopped.  If  these  measures  do  not  succeed  in  arresting 
the  inflammation,  and  particularly  if  the  process  be  severe,  it 
is  good  surgery  to  make  a  free  incision  into  the  affected  parts, 
even  before  pus  can  be  detected.  This  will  often  obviate  the 
formation  of  abscesses. 

In  regard  to  the  treatment  of  suppurative  disease,  whether 
superficial  or  deep,  free  incision  and  drainage  is  of  course  the 
only  measure  to  be  considered.  All  abscesses  are  to  be  opened 
at  once. 

The  incision  or  incisions  should  radiate  from  the  nipple  so 
as  not  to  divide  the  galactophorous  ducts.  In  superficial 
abscesses  it  will  suffice  to  effect  a  free  opening  and  provide  drain- 
age after  the  contents  are  evacuated.  In  deep  abscesses  where 
much  destruction  of  tissue  has  occurred  it  often  becomes 
necessary  to  make  counter-openings  and  institute  through  and 
through  drainage  by  means  of  rubber  tubes.  Cases  in  which 
the  purulent  collections  have  been  evacuated  spontaneously, 


34  Diseases  of  the  Breast. 

with  the  result  that  sinuses  have  been  left  behind,  require  care- 
ful and  most  thorough  attention.  Free  incisions  must  be  made, 
the  walls  of  the  sinuses  scraped,  and  the  partly  closed  abscess 
cavities  likewise  curetted.  In  such  cases  it  is  well  to  irrigate 
with  bichloride  of  mercury  solution  1-4000.  Drainage  is 
also  to  be  practised. 

In  retromammary  abscess  the  breast  is  to  be  lifted  up  and  a 
free  opening  made  at  the  mammary-thoracic  fold.  If  there  is 
suppuration  in  the  axilla,  a  free  opening  must  be  made  and 
the  space  drained.  In  these  cases  it  may  become  necessary  to 
turn  the  breast  up  as  in  the  operation  of  plastic  resection  of 
benign  growths  and  lay  abscess  cavities  freely  open,  thoroughly 
breaking  down  any  septa  or  remains  of  septa  which  may  be 
present  between  the  different  parts. 

In  suppuration  the  danger  consists  not  in  doing  too  much, 
but  in  doing  too  little.  Early  and  free  opening  of  the  affected 
parts  will  invariably  give  satisfactory  results,  whereas  delay, 
procrastination,  and  loathness  to  use  the  scalpel  freely  when  it 
is  employed  will  be  followed  by  extensive  destruction  of  tissue. 
It  is  especially  in  the  neglected  cases  that  extensive  procedures 
are  demanded,  and  it  is  certainly  true  that  timely  interference 
would  almost  invariably  have  been  conservative  of  the  mammary 
tissues  and,  moreover,  have  saved  the  patient  much  suffering. 

After  the  breast  has  been  opened  it  must  always  be  supported 
by  a  suitable  bandage  in  addition  to  the  usual  surgical  dressings. 
It  is  well  to  bandage  the  arm  to  the  side. 

The  drainage  tubes  are  withdrawn  gradually  as  healing 
takes  place.  For  cleansing  the  wounds  probably  nothing  is 
better  than  hot  normal  saline  solution,  although  in  cases  of 
virulent  infection,  one  or  two  irrigations  with  weak  bichloride 
(1-5000)  may  be  employed.  As  the  wounds  begin  to  grow 
healthy  the  formation  of  granulation  tissue  may  be  stimulated 
by  balsam  of  Peru.  Tonics  and  a  generous  diet  should  be 
given  to  maintain  the  patient's  strength. 


Inflammatory  Diseases  of  the   Breast.  35 

The  treatment  of  abscess  complicated  with  sinuses  has 
already  been  alluded  to.  In  obstinate  cases,  in  which  the  breast 
has  been  so  riddled  that  very  little  healthy  tissue  remains,  it 
has  been  necessary  to  perform  amputation.  This  is  a  very 
radical  procedure  and  should  be  employed  only  as  a  last  resort. 

If  there  be  only  one  or  two  sinuses  which  have  persisted, 
the  excision  of  a  wedge-shaped  piece  of  tissue  surrounding  the 
sinus,  after  the  method  practised  by  A.  Marmaduke  Sheild, 
will  often  effect  a  cure. 

The  treatment  of  suppurating  hematoma  differs  in  no  wise 
from  that  of  simple  abscess.  Cure  is  rapid  after  evacuation 
of  the  pus,  blood  and  clot. 

Chronic  Mastitis. 

The  term  chronic  mastitis,  as  understood  here,  is  applied 
to  a  chronic  inflammatory  process  affecting  the  mammary  gland 
and  characterized  by  the  formation  of  fibrous  tissue,  which 
results  in  compression  of  the  acini  and  ducts,  thus  leading  to 
atrophy,  and  sometimes  to  obliteration  of  these  structures. 
Another  change  which  not  uncommonly  occurs  is  cyst-forma- 
tion in  the  ducts,  due  to  the  occlusion  of  a  certain  portion  of 
their  lumen  and  consequent  dilatation  of  the  remaining  portion. 

It  is  also  certain  that  changes  in  the  epithelium  take  place 
in  a  certain  number  of  cases,  according  to  Warren  in  about 
one-half. 

The  process  may  be  localized  or  diffuse. 

In  regard  to  the  etiology  of  this  affection,  it  is  positively 
known  that  acute  inflammation  and  abscess  may  be  followed 
by  the  formation  of  fibrous  tissues  and  cicatricial  contraction. 
Cases  of  acute  mastitis  in  which  the  inflammatory  process  did 
not  advance  to  suppuration  frequently  fail  to  undergo  complete 
resolution,  areas  of  induration  persisting  indefinitely,  or  some- 
times undergoing  gradual  involution  until  they  finally  disappear. 
So,  too,  there  is  a  formation  of  fibrous  connective  tissue  to  re- 


36  Diseases  of  the   Breast. 

place  the  destruction  of  normal  mammary  tissue  incident  to  sup- 
purative disease.  In  like  manner  injury  may  also  give  rise  to 
the  same  tissue  changes,  blows  and  bruises  setting  up  conges- 
tive and  inflammatory  processes  which  are  followed  by  the 
formation  of  new  tissue  and  a  certain  degree  of  contraction, 
whereas  open  wounds  result  in  more  pronounced  though  similar 
changes  as  healing  occurs. 

Chronic  inflammation  of  the  breast  developing  as  the  result 
of  any  of  these  causes  is  not  at  all  difficult  to  understand, 
inasmuch  as  it  represents  the  usual  sequel  of  acute  inflam- 
mation and  suppuration.  Quite  different,  however,  are  those 
cases  in  which  there  are  no  distinct  antecedent  etiological  factors 
such  as  have  been  enumerated  above. 

First  of  all  it  is  necessary  to  admit  that  we  are  not  in  posses- 
sion of  complete  knowledge  in  regard  to  the  formation  of  fibrous 
tissue  in  the  various  organs  of  the  body.  Thus,  for  example, 
the  exact  manner  of  development  of  chronic  contracting  kidney 
and  cirrhosis  of  the  liver  is  not  absolutely  clear;  the  same  is 
true  of  the  formation  of  those  tumors  containing  much  fibrous 
tissue. 

As  regards  certain  cases  of  the  affection  under  consideration 
even  less  is  known  than  concerning  the  conditions  above  cited. 
Although  comparatively  little  has  been  written  relative  to  a  class 
of  cases  to  which  Franz  Konig  applied  the  term  diffuse  intersti- 
tial mastitis,  the  most  varied  opinions  have  been  expressed  about 
its  causes,  nature,  and  mode  of  development.  A  similar  diver- 
sity of  opinion  has  prevailed  in  regard  to  the  localized  form  of 
the  disease  occurring  irrespective  of  any  well-defined  causes. 
Reference  to  these  matters  will  be  made  again. 

It  is  well-known  to  all  surgeons  who  have  had  much  experi- 
ence with  diseases  of  the  mammary  gland,  that  it  is  not  unusual 
for  women  of  different  ages,  but  particularly  those  who  are 
near  the  menopause,  to  present  themselves  with  the  statement, 
that  they  have  either  discovered  one  or  more  hard  and  perhaps 


Inflammatory  Diseases  of  the   Breast.  37 

tender  areas  in  their  breast,  or  that  the  entire  breast  has  become 
swollen,  indurated,  and  more  or  less  painful.  Careful  inquiry 
fails  to  elicit  any  adequate  cause  for  the  supervention  of  such 
a  condition.  There  may  or  may  not  be  a  history  of  preg- 
nancy and  lactation  or  a  recollection  of  previous  injury  to  the 
breast. 

As  regards  the  relative  frequency  of  these  conditions  in  the 
married  and  unmarried,  I  am  of  the  opinion  that  it  is  rather 
more  common  in  the  former  class,  and  I  believe  that  this  view 
is  sustained  by  the  experience  of  other  observers. 

Upon  what  can  these  conditions  depend?  What  are  the 
factors  leading  to  the  production  of  tissue  metamorphosis? 

In  answer  to  these  questions  I  will  state  that  I  believe  the 
structural  changes  are  associated  with  and  represent  variations 
from  the  normal  function  of  the  gland.  When  considering 
the  physiology  of  the  breast  attention  was  directed  to  the 
destruction  and  reproduction  of  tissue  incident  to  lactation,  and 
also  to  the  intimate  relation  existing  between  the  mammary 
gland  and  the  reproductive  organs.  Moreover,  it  was  stated 
that  function  and  structure  are  inseparable,  that  variations 
of  the  former  depend  upon  alterations  in  the  latter. 

Irrespective  of  the  acute  diseases  to  which  the  breast  is  sub- 
jected during  lactation,  certain  conditions  which  may  obtain  in 
it  during  the  periods  of  involution  and  evolution,  particularly 
if  they  be  frequently  repeated,  seem  to  me  to  be  especially 
conducive  to  the  development  of  the  affection  under  considera- 
tion. Thus,  failure  of  complete  rehabilitation  throughout  the 
entire  gland  may  very  likely  lead  to  an  undue  proliferation  of 
cells  resulting  in  the  production  of  connective  tissue.  It  is 
not  improbable  that  the  effect  of  rapidly  repeated  pregnancies, 
necessitating  evolutionary  changes  in  the  gland  before  a  period 
of  repose  can  be  had  after  its  recent  involution,  might  act  as  a 
stimulus  to  aberrations  of  tissue  formation. 

These  views,  although  largely  speculative,  seem  to  be  worthy 


38  Diseases  of  the   Breast. 

of  consideration,  as  they  are  based  upon  well-established  prin- 
ciples of  physiology  and  pathology. 

In  regard  to  those  cases  occurring  in  women  who  have  never 
been  pregnant  nor  borne  children,  it  may  be  assumed  that  the 
very  deprivation  of  normal  function  to  which  the  gland  has 
been  subjected  may  have  stimulated  the  glandular  structures 
to  compensatory  though  abortive  efforts  to  functionate,  with  the 
result  that  tissue  changes  are  set  up  which  lead  to  the  same 
alterations  in  structure  as  have  been  supposed  to  be  produced 
by  the  excessive  stimulation  incident  to  frequently  occurring 
periods  of  involution  and  evolution. 

Another  factor  to  which  I  believe  not  enough  importance 
has  been  attached,  and  one  to  which,  so  far  as  I  am  aware,  no 
writers  have  called  attention,  is  the  interruption  of  pregnancy, 
with  the  consequent  sudden  arrest  of  evolutionary  changes  in  the 
breast  and  the  establishment  of  involutionary  changes  before  the 
period  of  evolution  and  lactation  has  been  completed.  It  seems 
probable  that  such  a  departure  from  the  normal  cycle  of  changes 
through  which  the  mammary  tissues  pass  during  pregnancy  and 
lactation  might  well  give  rise  to  disturbances  of  their  rehabilita- 
tion, or  lead  to  an  abnormal  proliferation  of  cells  capable  of 
giving  rise  to  this  morbid  process.  I  have  seen  women  who 
aborted  during  the  fourth  and  fifth  months  of  pregnancy  suffer 
considerably  with  swelling  and  soreness  of  the  breast.  This 
is  certainly  indicative  of  disturbed  function. 

Many  cases  of  abortion,  particularly  those  which  are  crimin- 
ally induced  in  illegitimate  pregnancies,  are  scrupulously  con- 
cealed, so  that  no  history  whatsoever  can  be  obtained.  Under 
such  circumstances  the  most  that  can  be  done  is  to  infer  the  pre- 
vious existence  and  interruption  of  pregnancy,  if  the  general  as- 
pect of  the  breasts  lead  one  to  suspect  that  it  has  occurred. 
This,  however,  is  not  of  great  help,  as  the  majority  of  abortions 
are  induced  before  pregnancy  has  advanced  far  enough  to  leave 
its  permanent  signs  upon  the  breasts. 


Inflammatory  Diseases  of  the  Breast.  39 

It  is  questionable  whether  some  cases  ,in  which  diffuse 
chronic  mastitis  is  supposed  to  exist  are  not  merely  cases  in 
which  the  senile  atrophy  of  the  breast  has  taken  place  more 
rapidly  than  usual  or  began  to  develop  at  an  earlier  age.  The 
frequent  occurrence  of  this  condition  in  women  who  are  at  the 
menopause,  a  period  during  which  the  mammary  tissues  are 
most  unstable,  is  certainly  suggestive  of  involuntary  changes. 
I  believe  this  is  a  matter  worthy  of  the  most  serious  considera- 
tion and  one  to  which  observation  and  investigation  may  well 
be  directed. 

The  cases  occurring  in  young  girls  shortly  after  puberty  also 
point  strongly  to  a  deviation  from  the  normal  process  of  evolu- 
tion through  which  the  gland  goes  at  this  epoch  of  life. 

From  what  has  been  stated  it  is  evident  that  the  etiology  of 
chronic  mastitis  is  far  from  being  thoroughly  understood,  and 
that  it  is  a  subject  fit  for  further  study.  The  theories  which  I 
advance  relative  to  the  causation  of  some  of  the  cases  of  ob- 
scure origin  seem  to  me  to  be  at  least  plausible,  if  not  indeed 
affording  a  reasonable  explanation  of  their  development. 

Pathology. — The  predominant  alteration  in  structure  is  an 
increase  in  fibrous  tissue.  Two  views  have  been  entertained 
in  regard  to  the  origin  of  this  tissue;  some  have  held  that  the 
changes  begin  in  the  glandular  elements,  while  others  hold  that 
the  interstitial  connective  tissue  is  primarily  affected.  Konig, 
who  formerly  favored  the  latter  view,  has  now  come  to  regard 
the  former  as  correct  and  accordingly  has  discarded  the  term 
interstitial  which  he  employed  in  referring  to  chronic  diffuse 
mastitis. 

If  a  section  from  such  a  mammary  gland  be  examined 
microscopically,  a  plentiful  distribution  of  fibrous  tissue 
around  the  ducts  will  be  seen,  and  furthermore  it  will  be  ob- 
served that  the  masses  of  fat  in  the  interstitial  tissue  are  com- 
pletely surrounded  by  the  fibrous  tissue,  being  encapsulated, 
so   to  speak.      The  new  tissue  appears  in  various  stages  of 


40  Diseases  of  the   Breast. 

development.  It  is  frequently  infiltrated  with  leucocytes  in  its 
earlier  stages. 

Allusion  has  already  been  made  to  the  changes  occurring  in 
the  galactophorous  ducts.  The  cysts  which  are  formed  are  due 
to  obliteration  of  the  lumen  of  the  ducts  with  consequent 
dilatation  of  the  portion  remaining  patent.  They  are,  there- 
fore, retention  cysts,  pure  and  simple.  They  vary  in  size, 
some  being  very  minute  and  others  fairly  large.  In  the  small 
ones  healthy  epithelium  is  seen,  whereas  in  those  of  larger  size 
degenerated  cells  are  sometimes  observed.  The  contents 
of  these  cysts  also  varies  both  as  to  color  and  consistency, 
being  thin  and  clear  in  some  instances  and  viscid  and  dark 
colored  in  others:     The  former  condition  is  the  more  common. 

It  not  infrequently  happens  that  a  portion  of  the  duct  becomes 
completely  obliterated  and  atrophied,  being  converted  into  a 
small,  dense,  fibrous  cord. 

In  those  cases  of  chronic  mastitis  following  acute  inflammation 
or  injury,  and  in  which  the  disease  is  localized  rather  than  diffuse, 
the  fibrous  tissue  seems  to  form  more  rapidly,  so  that  oblitera- 
tion of  the  ducts  without  cyst-formation  is  the  rule.  Macro- 
scopically  such  breasts  present  dense  areas  of  fibrous  tissue  sit- 
uated in  different  parts  of  the  gland,  their  location  of  course 
depending  upon  the  site  of  the  primary  disease.  Carcinomat- 
ous degeneration  may  take  place  in  a  breast  thus  affected; 
when  such  change  occurs  the  altered  glandular  tissue  will  be 
found  imbedded  in  the  dense  fibrous  tissue  everywhere  present 
in  the  section.  They  may  follow  the  line  of  the  minute  lym- 
phatics of  the  breast,  as  in  a  case  described  by  Whitney. 

The  symptoms  and  course  of  chronic  mastitis  are  variable. 
Sometimes  it  begins  suddenly  with  pain  and  swelling  of  the 
breast,  while  at  others  its  onset  is  gradual.  During  the  men- 
strual periods  the  symptoms  become  intensified.  Occasionally 
the  symptoms  subside  after  a  few  months,  but  as  a  rule  the 
disease  is  progressive.     In  the  localized  form  pain  and  uneasi- 


Inflammatory  Diseases  of  the  Breast.  41 

ness  in  the  indurated  areas  are  the  only  symptoms,  and  even 
these  may  be  absent. 

In  the  diffuse  form  the  disease  may  be  mistaken  for  begin- 
ning scirrhus  carcinoma,  particularly  if  the  onset  has  been  insid- 
ious. In  the  absence  of  a  clear  history  large  isolated  nodules 
may  also  lead  to  confusion  with  the  same  form  of  malignant 
disease. 

Treatment  is  unsatisfactory,  especially  in  cases  developing 
without  any  well-defined  cause.  When  inflammation  and 
induration  remain  after  acute  processes,  compression  and  the 
use  of  iodine  and  belladonna  ointments  in  equal  parts  sometimes 
seems  to  favor  resolution.  Ichthyol  ointment  (30  percent) 
may  be  used  instead  if  preferred. 

Chronic  Abscess. 

If  an  indurated  area  which  is  formed  during  or  shortly 
after  the  puerperium  undergoes  softening  after  a  period  of 
several  weeks,  instead  of  continuing  to  subside,  a  chronic 
abscess  results.  Such  an  indurated  area  may  undergo  partial 
though  not  complete  resolution,  remain  stationary  for  a  long 
time,  and  then  for  some  unknown  reason  advance  to  suppuration. 
In  such  cases  it  is  not  improbable  that  the  virulence  of  the 
microorganisms  becomes  attenuated,  so  that  they  lie  dormant 
until  some  exciting  cause  arouses  them  to  renewed  activity. 
Another  explanation  for  the  development  of  these  slow  sup- 
purative processes  is  afforded  by  the  supposition,  that  micro- 
organisms transmitted  through  the  blood  lodge  in  the  tissues  of 
the  mammary  gland,  the  vitality  of  which  has  been  impaired 
by  previous  disease,  and  set  up  a  low  form  of  inflammation. 

Whatever  the  origin  of  these  chronic  abscesses,  whether  they 
are  residual  processes  of  acute  inflammation  or  develop  from 
causes  which  are  indeterminable,  an  essential  fact  to  remember 
is  that  they  merely  represent  a  slow  form  of  suppuration. 

Sometimes  an  injury  may  be  followed  after  the  lapse  of 


42  Diseases  of  the  Breast. 

weeks  or  months  by  the  formation  of  an  abscess,  which  in  all 
probability  is  due  to  the  lowered  power  of  resistance  in  the 
tissue  caused  directly  by  the  injury,  the  changed  condition 
resulting  therefrom  being  favorable  to  the  growth  of  micro- 
organisms. 

The  development  and  duration  of  these  abscesses  is  most 
variable. 

Klotz  has  reported  a  case  in  a  woman,  twenty  years  of  age, 
who  had  suffered  two  years  before  with  an  acute  mastitis, 
from  which,  however,  she  apparently  had  completely  recovered. 
A  hard  nodule  appeared  in  her  breast,  slowly  increased  in 
size,  and  finally  began  to  soften.  This  mass  was  incised  and 
proved  to  be  a  sack  filled  with  pus.  Even  more  remarkable 
than  this  is  a  case  reported  by  Reclus.  In  this  case  a  nodule 
which  developed  shortly  after  delivery  remained  stationary  for 
six  years  and  then  suppurated. 

These  abscesses  vary  in  size,  although  as  a  rule  they  do  not 
become  larger  than  a  hen's  egg.  They  may  be  irregular  in 
form  or  round  and  well  defined.  The  skin  may  or  may  not 
become  adherent.  In  either  case  the  abscess  is  movable  with 
the  rest  of  the  gland.  Tenderness  to  pressure  is  a  constant 
symptom,  and  enlargement  of  the  axillary  glands  is  also  very 
common. 

A  chronic  abscess  has  been  mistaken  for  malignant  disease, 
particularly  sarcoma.  The  slower  development,  the  associated 
pain  and  enlargement  of  the  axillary  glands,  together  with  the 
history  of  the  case  will  serve  to  distinguish  it  from  sarcoma. 
Abscess  is  differentiated  from  carcinoma  by  its  more  rapid 
development,  the  earlier  involvement  of  the  axillary  glands,  and 
the  invariable  tenderness  to  pressure. 

Treatment  consists,  of  course,  in  free  incision  and  drainage. 


TUBERCULOSIS. 

Although  Virchow  in  his  treatise  on  the  Pathology  of 
Tumors  included  the  mammary  gland  among  the  organs  not 
subject  to  tuberculosis,  reference  to  scrofulous  affections  of 
the  breast  had  been  made  long  before  by  Sir  Astley  Cooper, 
and  Velpeau  had  also  discussed  tuberculous  tumors  in  a  vague 
and  indefinite  manner,  recognizing,  however,  three  forms, 
which  he  called  disseminated  tumor,  lymphatic  tumor,  and 
lymphatic  degeneration.  Other  surgeons  also  reported  a  case 
now  and  then,  but  it  was  not  until  1881  that  Dubar  made  the 
first  scientific  study  of  the  disease.  To  him  belongs  the  credit 
of  first  demonstrating  the  tubercle  bacillus  in  the  mammary 
tissues.  Ten  years  later  Roux  called  attention  to  intramam- 
mary  cold  abscess. 

Although  rare,  tuberculosis  of  the  breast  is  probably  more 
common  than  it  has  been  considered  to  be.  In  more  than 
fifteen  hundred  cases  of  disease  of  the  mammary  gland  ad- 
mitted to  St.  Bartholomew's  Hospital,  London,  Sidney  R.  Scott 
found  1.5  percent  to  be  tuberculosis.  While  it  is  true  that  the 
number  of  cases  occurring  in  literature  which  have  been  veri- 
fied by  finding  tubercle  bacilli  or  tubercles  in  the  tissues  exam- 
ined is  small — Schley  having  found  only  sixty-five  up  to  1903 — 
it  is  probable  that  more  careful  observations  will  prove  the  dis- 
ease to  be  commoner  than  it  has  usually  been  thought  to  be. 

As  in  other  organs,  so  in  the  mammary  gland,  tuberculosis 
may  be  primary  or  secondary.  Although  it  is  true  that  the 
disease  cannot  positively  be  stated  to  be  primary  unless  an 
autopsy  be  held  and  the  presence  of  a  concealed  tuberculous 
focus  excluded,  still  for  practical  purposes  those  cases  in  which 

43 


44  Diseases  of  the   Breast. 

there  are  no  other  demonstrable  foci  may  be  regarded  as 
primary. 

In  this  form  the  infection  no  doubt  takes  place  through 
the  blood  current  or  results  from  direct  infection  from  without. 
The  latter  mode  is  no  doubt  rare.  That  tubercle  bacilli  might 
gain  access  to  the  mammary  gland  through  an  open  wound  or  an 
abrasion  is,  of  course,  not  to  be  disputed,  and  that  there  is  a 
possibility  of  their  gaining  entrance  through  the  galactophorous 
ducts  is  likewise  not  to  be  denied.  Indeed  the  latter  mode 
of  entry  has  been  strongly  upheld  by  Verneuil.  So  far  as  I  have 
been  able  to  determine,  however,  the  lesions  are  more  pro- 
nounced in  the  alveoli  than  in  the  ducts,  and,  moreover,  the 
ducts  themselves  are  generally  not  more  diseased  near  their  exit 
at  the  nipple  than  they  are  further  in  the  interior  of  the  gland. 
Were  the  infection  to  take  place  through  these  ducts  it  is  only 
natural  to  suppose  the  primary  lesion  would  develop  close  to 
their  orifices  and  that  the  disease  would  be  more  advanced  there 
than  in  the  parenchyma  of  the  gland  itself.  While  no  decisive 
statement  can  be  made  in  regard  to  this  matter  until  further 
observation,  based  upon  a  greater  number  of  cases,  has  been 
made,  in  view  of  the  chief  location  of  the  morbid  process,  and 
likewise  in  consideration  of  our  knowledge  of  the  mode  of  tuber- 
culous infection  in  other  organs  of  the  body,  particularly  the 
genito-urinary  organs,  I  am  of  the  opinion  that  the  usual  mode 
of  primary  infection  of  the  mammary  gland  is  through  the  blood 
current.  In  this  connection  it  is  interesting  to  note  that  Kitt, 
who  has  studied  bovine  tuberculosis  thoroughly,  states  that 
tuberculosis .  of  the  udders  is  almost  always  of  hematogenous 
origin. 

When  secondary  the  infection  may  extend  from  neighboring 
structures,  as,  for  instance,  the  pleura  or  ribs,  or  it  may  be  trans- 
mitted through  the  blood  current  from  a  focus  in  a  remote  por- 
tion of  the  body,  or  be  carried  by  the  lymphatics  from  a  diseased 
gland  in  the  axilla  or  in  the  supraclavicular  triangle. 


Tuberculosis.  45 

Halsted  believes  that  invasion  by  way  of  the  lymphatics 
constitutes  the  primary  mode  of  infection,  even  maintaining 
that  those  cases  which  are  usually  considered  primary  are  in 
reality  secondary,  being  due  to  the  transference  of  tubercle 
bacilli  from  other  parts  of  the  body,  principally  the  axillary 
and  mediastinal  glands,  through  the  lymph  stream. 

Considerable  has  been  written  concerning  the  relative  fre- 
quency of  the  primary  and  secondary  forms,  and  much  differ- 
ence of  opinion  has  been  expressed.  As  has  already  been  said, 
it  is  impossible  to  state  positively  that  a  case  is  primary,  unless 
every  organ  of  the  body  can  be  examined  and  the  absence  of 
tuberculous  foci  excluded.  In  regard  to  the  relative  frequency 
of  those  cases  which  are  denominated  primary  because  there 
are  no  other  demonstrable  lesions,  and  those  in  which  it  is  plain 
that  the  disease  is  secondary,  it  is  evident  that  a  larger  number  of 
observations  must  be  made  before  any  definite  conclusions  can 
be  drawn. 

Some  difference  of  opinion  has  been  expressed  as  to  whether 
the  disease  begins  within  the  acini  or  in  the  connective  tissue, 
but  the  weight  of  evidence  is  strongly  in  favor  of  the  former 
view. 

Concerning  the  etiology  of  mammary  tuberculosis,  it  may 
be  said  that  the  disease  occurs  much  more  frequently  in  females 
than  in  males,  and  that  it  affects  young  women  oftener  than  it 
does  those  of  middle  or  old  age.  It  may,  however,  occur  at 
any  period  from  puberty  to  senility.  As  a  greater  number  of 
cases  are  reported  it  may  be  found  that  the  disease  shows  a 
greater  predilection  to  develop  during  a  certain  decade  than  at 
any  other  time.  Out  of  thirty-two  cases  studied  by  Delbet, 
eighteen  were  in  women  between  the  ages  of  twenty-five  and 
thirty-five.  Schley  found  the  disease  to  be  equally  common 
during  the  third,  fourth  and  fifth  decades.  Of  eleven  cases 
recently  reported  from  Bruns'  clinic  at  Tubingen  one  occurred 
in  the  twenty-fifth  year  of  life,  four  in  the  thirtieth,  four  in  the 


46  Diseases  of  the  Breast. 

fortieth,  and  two  in  the  fiftieth.  It  has  been  stated  that  no 
cases  have  been  observed  after  the  menopause,  but  in  looking 
over  the  literature  of  the  subject  I  found  one  reported  in  a 
woman  of  seventy. 

Heredity  seems  to  exert  no  greater  influence,  if  indeed  it  be 
as  great,  than  in  the  production  of  tuberculosis  in  other  organs 
of  the  body. 

Previous  inflammatory  diseases  and  injury  are  naturally  to 
be  considered  as  predisposing  causes.  By  lowering  the  vital- 
ity of  the  mammary  tissues  they,  no  doubt,  prepare  a  favorable 
soil  for  the  reception  and  growth  of  the  specific  microorganisms. 

Tuberculosis  in  other  parts  of  the  body  of  course  predisposes 
to  secondary  involvement  of  the  breast.  Thus,  Mandry  found 
an  associated  tuberculous  affection  in  one-half  of  the  cases 
which  he  studied. 

Some  investigators  have  attributed  a  considerable  influence 
to  pregnancy  and  lactation  as  predisposing  factors,  whereas 
others  have  flatly  denied  that  they  are  of  any  etiological  sig- 
nificance whatsoever.  It  is  probable  that  the  only  causative 
effect  which  can  reasonably  be  attributed  to  these  processes 
is  a  secondary  one,  that  is,  they  predispose  to  tuberculous  infec- 
tion only  in  so  far  as  they  lower  the  vitality  of  the  mammary 
tissues  by  giving  rise  to  inflammation  or  abscess,  and  thus  pro- 
duce a  more  favorable  soil  for  the  reception  and  growth  of  any 
tubercle  bacilli  which  perchance  may  gain  access  to  the  gland. 

Pathology. — A  discrete  and  confluent  form  are  usually  recog- 
nized. In  addition  to  these  two  forms  intraglandular  mammary 
abscess  and  miliary  tuberculosis  have  been  described.  The 
last  mentioned  occurs  as  a  part  of  a  general  miliary  tubercu- 
losis and,  therefore,  may  be  dismissed  from  further  consid- 
eration. 

In  the  discrete  form  there  are  a  few  isolated  tubercles  which 
are  separated  by  apparently  healthy  tissue.  These  tubercles 
may  undergo  the  ordinary  changes  which  occur  in  all  tubercles 


Tuberculosis.  47 

and  still  remain  isolated,  or,  owing  to  the  dissemination  of  in- 
fection from  them,  new  tubercles  may  form  in  the  intervening 
healthy  tissue  so  that  a  larger  area  becomes  involved.  If  the 
morbid  process,  advances,  coalescence  of  these  tubercles  may 
take  place  and  the  confluent  form  of  the  disease  result.  Indeed 
any  difference  between  the  two  usually  recognized  forms  of 
mammary  tuberculosis  has  been  denied,  and  it  seems  not 
improbable  that  the  actual  difference  is  in  the  degree  of  inten- 
sity of  the  infection  and  the  resistive  power  of  the  tissues  rather 
than  in  the  morbid  process  itself. 

The  isolated  tubercles  vary  in  size,  some  being  no  larger 
than  a  pea  while  others  are  as  big  as  a  hazel-nut.  If  caseation 
and  liquefaction  occur  abscesses  develop. 

In  the  confluent  form  a  swelling  of  considerable  size  is  pres- 
ent in  the  breast.  This  tumefaction,  however,  is  often  not 
sharply  limited,  being  ill-defined  and  irregular  and  presenting 
bosselations  over  its  surface.  When  cut  into  during  the  early 
stages  of  its  evolution  such  a  tumor  is  found  to  be  of  a  white 
or  grayish  color  and  of  firm  consistency.  In  the  later  stages, 
although  this  appearance  may  still  be  retained  at  the  periphery, 
the  center  will  have  become  yellow  in  color.  If  liquefaction 
occurs,  an  abscess  is  formed,  the  so-called  intramammary 
cold  abscess  of  Roux.  In  some  cases  softening  and  lique- 
faction is  limited  to  certain  parts  of  the  tumor,  so  that  small 
abscesses  alternate  with  areas  of  indurated  tubercle.  It  may  be 
that  the  greater  portion  of  the  tumor  has  undergone  liquefaction, 
but  that  certain  portions  have  remained  intact,  persisting  as 
trabeculae  between  the  various  cavities  of  the  abscess.  The 
walls  of  a  tuberculous  mammary  abscess  do  not  differ  from 
those  of  a  tuberculous  abscess  in  other  soft  tissues,  being  thick 
and  lardaceous  and  covered  with  granulations  and  tubercles. 

The  microscopic  appearance  of  a  mammary  gland  affected 
with  tuberculosis  varies  according  to  the  stage  of  the  disease 
in  which  it  is  examined.     If  seen  at  the  very  beginning  it  is 


48      v  Diseases  of  the   Breast. 

probable  that  no  changes  other  than  simple  inflammation  could 
be  detected.  Early  in  the  development  of  the  morbid  process 
the  alveoli  and  ducts  are  still  discernible  and  plainly  recogniz- 
able. Later  the  alveoli  disappear,  granulation  tissue  is  dis- 
seminated throughout  the  lobule,  and  giant  cells  are  seen. 
There  may  be  such  an  infiltration  of  embryonal  tissue  in  the 
interstices  between  the  alveoli  as  completely  to  destroy  the  lat- 
ter structures.  This  new  tissue  also  contains  giant  cells.  Some- 
times beginning  tubercle-formation  can  be  detected  in  adjoining 
lobules.  The  same  changes  occur  around  the  ducts,  although 
the  alveoli  are  first  attacked  as  a  rule,  the  embryonal  tissue 
compresses  or  invades  these  structures,  just  as  it  does  the  alveoli, 
and  thus  leads  to  their  partial  or  complete  destruction.  In  some 
sections  studied,  only  the  changes  of  simple  inflammation  were 
apparent  around  the  ducts,  although  the  typical  alterations  of 
tuberculosis  involved  the  alveoli.  The  walls  are  thickened  by 
an  infiltration  of  leucocytes  which  may  even  extend  into  the 
lumen  of  the  ducts.  Granulations  may  also  be  present.  Tuber- 
cle bacilli  are  very  rare  in  the  tissue  and  many  sections  may  be 
examined  before  any  are  found.  The  diseased  tissue  is  also 
poor  in  blood-vessels. 

Four  cases  of  tuberculosis  of  the  breast  associated  with 
carcinoma  have  been  recorded,  and  one  associated  with  adenoma 
has  also  been  reported  by  E.  P.  Davis.  In  the  first  class  the 
symptoms  of  tuberculosis  predominated  and  the  macroscopic 
appearance  of  the  diseased  tissue  was  suggestive  of  tuberculosis 
rather  than  of  malignant  disease.  Microscopic  examination, 
however,  demonstrated  the  presence  of  carcinoma  cells  in  the 
diseased  area. 

Two  of  these  cases  were  reported  in  the  American  Journal 
of  the  Medical  Sciences,  July,  1899,  by  A.  S.  Warthen,  of 
Ann  Arbor,  Michigan.  In  one  case  it  is  probable  that  tuber- 
culosis constituted  the  primary  lesion;  in  the  other,  however, 
the  carcinoma  was  undoubtedly  primary. 


PLATE  III. 


Tuberculosis.    Microscopic  appearance.     (Drawing  made  from  a  specimen 
loaned  by  Dr.  A.  O.  J.  Kelly,  of  Philadelphia.) 


Tuberculosis.  51 

Pilliet  and  Piatot  {Bull,  de  la  Soc.  Anal,  de  Paris,  May, 
1897),  reported  another  case  occurring  in  a  male  aged  fifty-one 
years. 

The  fourth  case  was  reported  by  Kallenberg  in  his  Tubingen 
thesis  for  1902. 

Rokitansky's  teaching  that  carcinoma  and  tuberculosis 
never  occur  simultaneously  is  now  known  to  be  erroneous,  and 
Rokitansky  himself  modified  his  theory  as  far  as  to  admit  that, 
though  exceedingly  rare,  the  two  might  be  combined.  A 
number  of  cases  are  on  record  in  which  the  two  have  been  found 
associated  in  different  organs  of  the  body. 

That  their  simultaneous  occurrence  in  the  mammary  gland 
is  most  unusual  is  shown  by  the  paucity  of  cases  thus  far  re- 
ported. Kallenberg  was  unable  to  find  a  single  case  recorded 
in  German  literature  at  the  time  he  wrote  his  thesis  in  1902. 

Whether  the  combination  is  entirely  fortuitous  or  whether 
one  lesion  gives  rise  to  the  other  is  unknown.  Whether  the 
irritation  produced  by  tubercle  sets  up  an  abnormal  prolifera- 
tion of  epithelial  cells  resulting  in  the  formation  of  a  malignant 
neoplasm  or  whether  tuberculous  infection  is  superimposed 
upon  the  carcinomatous  process  has  not  been  positivelv  deter- 
mined. 

This  combination  of  tuberculosis  and  carcinoma  is  so  rare 
that  it  is  of  pathological  rather  than  clinical  interest. 

Symptoms. — The  onset  of  tuberculosis  of  the  breast  is  insidi- 
ous and  its  development  usually  slow,  although  lactation  seems 
to  stimulate  the  morbid  process  to  more  rapid  growth.  The 
disease  may  last  for  months  or  years.  It  is  remarkable  that 
only  one  breast  is  affected. 

In  the  discrete  form  areas  of  induration  are  detected  in  var- 
ious portions  of  the  gland,  in  some  cases  being  distinctly  separ- 
ated from  the  surrounding  tissue,  while  in  others  the  outline  is 
indistinct.  In  this  form  there  is  not  much  enlargement  unless 
nodules  situated  close  to  one  another  coalesce  and  soften,  in 


52  Diseases  of  the  Breast. 

which  case  the  products  of  liquefaction  may  give  rise  to  a  dis- 
tinct tumor. 

Isolated  tubercles  vary  considerably  as  to  their  evolution. 
They  may  remain  stationary  for  a  considerable  time  or  grad- 
ually increase  in  size. 

Early  in  the  disease  the  skin  is  not  adherent,  but  often 
becomes  so  in  the  later  stages.  Fistulae  may  also  form.  Pain, 
too,  is  usually  not  severe  at  first,  although  it  may  become  so  as 
the  morbid  process  progresses. 

The  confluent  form  is  of  more  rapid  evolution,  fistulae  form- 
ing much  earlier  than  in  the  discrete  form.  A  solid  mass  is 
present,  varying  in  size  from  a  walnut  to  an  orange,  and  being 
hard  or  soft  according  to  the  stage  in  which  it  is  examined. 
The  outline  of  such  a  tumor  is  usually  not  clearly  defined,  but 
somewhat  irregular.  The  most  common  site  is  the  superior 
external  quadrant.  In  the  majority  of  cases  the  axillary  glands 
are  enlarged.  They  generally  increase  rapidly  in  size  and  may 
go  on  to  suppuration.  Retraction  of  the  nipple  due  to  sclerosis 
of  the  subjacent  tissues  has  also  been  seen. 

The  tendency  of  these  tuberculous  areas  is  to  liquefaction 
and  abscess-formation. 

Variations  from  the  usual  manifestations  of  the  disease  as 
above  described  have  been  observed.  Thus,  for  instance, 
Orthman  saw  a  case  in  which  the  infection  apparently  occurred 
from  without,  the  first  lesion  which  appeared  resembling  a 
simple  furuncle.  Instead  of  healing,  however,  its  base  became 
ndurated,  and  as  it  progressed  in  its  development  its  true  na  ture 
was  revealed.  Kramer  has  reported  a  case  in  which  the  dis- 
ease began  as  an  ulceration  of  the  nipple. 

Such  manifestations,  however,  are  unusual. 

Diagnosis. — The  diagnosis  of  mammary  tuberculosis  may 
be  very  difficult.  This  is  particularly  true  of  the  cases  which 
are  seen  early,  before  much  or  any  destruction  of  tissue  has  taken 
place.     Naturally   those   cases  in  which  fistulae  are  present, 


Tuberculosis.  53 

together  with  marked  enlargement  of  the  axillary  glands,  offer 
less  difficulty  than  those  seen  at  an  earlier  period  of  their  evolu- 
tion. It  is  likewise  the  case  when  tuberculous  foci  in  other 
parts  of  the  body  can  be  readily  detected.  A  tuberculous 
abscess  has  been  mistaken  for  a  cyst,  and  also  for  a  chronic 
abscess.  In  tuberculosis,  however,  the  usual  pronounced  en- 
largement of  the  axillary  glands  will  serve  as  a  point  of  differen- 
tial diagnosis. 

In  the  early  stages  the  disease  might  be  confused  with 
actinomycosis,  although  in  the  later  stages  the  presence  of  the 
ray-fungus  in  the  discharge  would  afford  a  positive  means 
of  differential  diagnosis. 

A  few  isolated  tubercles  might  also  be  mistaken  for  syphil- 
itic lesions,  but  the  history  and  progress  of  the  case  and  the 
failure  of  antisyphilitic  treatment  would  reveal  the  true  nature 
of  the  affection. 

Cases  of  tuberculosis  have  been  mistaken  for  carcinoma, 
and  vice  versa.  In  carcinoma  the  early  adherence  of  the  tumor 
to  the  skin,  the  slower  enlargement  of  the  axillary  glands  and 
their  greater  hardness  are  circumstances  valuable  in  distinguish- 
ing between  the  two  affections. 

The  age  of  the  patient  should  also  be  taken  into  consideration, 
as  the  majority  of  carcinomata  occur  in  women  after  middle  life. 
Tuberculosis,  however,  seems  to  show  a  greater  predilection 
for  young  women,  although  many  cases  have  occurred  in  women 
past  forty. 

Prognosis. — In  cases  in  which  no  other  tuberculous  lesions 
are  present  the  prognosis  may  be  considered  good,  provided 
all  the  diseased  tissue  is  removed  and  the  axilla  thoroughly 
freed  of  enlarged  glands.  Recurrences,  however,  have  been 
known  to  take  place. 

In  cases  in  which  other  demonstrable  tuberculous  foci  are 
present  the  prognosis  is  of  course  somewhat  influenced  by  the 
nature  and  extent  of  these  lesions.     As  regards  the  effect  of  the 


54  Diseases  of  the  Breast. 

morbid  process  upon  the  gland  itself,  it  will  suffice  to  say  that 
extensive  destruction  of  tissue  may  result.  Some  interesting 
statistics  bearing  on  prognosis  have  recently  been  reported  by 
Braendle,  one  of  Bruns'  assistants  at  the  Tubingen  clinic.  Out 
of  sixteen  patients  whose  history  was  followed  after  operation 
fifteen  were  cured.  The  time  elapsing  from  operation  to  the 
publication  of  his  report  varied  from  one  to  nineteen  years. 
Of  these  fifteen  patients  three  succumbed  to  phthisis  a  number 
of  years  after  operation;  no  local  recurrence,  however,  took 
place.     In  no  case  was  the  other  breast  involved. 

Treatment. — Tuberculosis  of  the  mammary  gland  has  been 
treated  by  curetting  and  cauterizing  the  sinuses,  by  excising  a 
wedge-shaped  portion  of  the  gland  containing  the  diseased 
area,  and  by  amputating  the  breast.  It  remains  to  be  shown 
that  anything  short  of  amputation  is  a  certain  and  safe  proce- 
dure, inasmuch  as  no  one  can  tell  whether  the  disease  is  not 
already  implanted  in  portions  of  the  breast  which  are  apparently 
healthy,  so  that  recurrence  may  take  place  even  though  it  seems 
that  all  diseased  tissue  has  been  removed.  Notwithstanding 
this  fact  I  believe  it  justifiable  to  practise  partial  resection  in 
the  discrete  form  of  the  disease  and  even  in  those  diffuse  cases 
in  which  a  considerable  portion  of  the  breast  is  apparently 
uninvolved.  Such  a  course  of  procedure  may  save  the  patient, 
often  a  young  unmarried  woman,  from  a  needless  mutilation, 
which  would  seriously  impair  her  chances  of  matrimony. 
The  favorable  results  obtained  by  this  procedure  have  been 
attested  by  the  experience  of  a  number  of  surgeons.  Many 
good  surgeons  are  now  advocating  resection  of  the  epididymis 
in  cases  of  tuberculosis  affecting  the  testicle  as  well  as  this 
organ,  believing  that  Nature  will  complete  the  cure  after  the 
primary  focus  has  been  removed.  Certainly  a  similar  conserva- 
tive procedure  is  worthy  of  trial  in  mammary  tuberculosis.  Any 
signs  of  recurrence  call  for  immediate  amputation  of  the  breast. 
The  axilla  should  always  be  cleared  of  all  diseased  glands. 


Tuberculosis.  55 

If  operation  be  refused,  injections  of  an  ethereal  solution  of 
iodoform  may  be  made  into  the  diseased  area.  Cuneo  states 
that  intramammary  cold  abscess  yields  more  readily  to  this 
treatment  than  other  forms  of  mammary  tuberculosis. 

At  the  present  day  probably  no  article  upon  the  treatment 
of  local  tuberculosis  would  be  complete  without  some  men- 
tion being  made  of  Wright's  bacterial  vaccines,  which  are  used 
in  conjunction  with  a  careful  observation  of  the  opsonic  power 
of  the  blood.  Wright  discovered  in  the  serum  of  the  blood  a 
substance  named  by  him  "opsonin,"  which  appears  to  act  upon 
the  bacteria  in  such  a  manner  as  to  render  them  easy  prey 
for  the  phagocytic  leucocytes  of  the  blood,  and  without  which 
the  leucocytes  are  feebly  or  negatively  phagocytic  to  the  bac- 
teria. He  also  found  that  by  introducing  minute  but  carefully 
estimated  doses  of  the  dead  bacteria,  he  could  increase  the 
amount  of  this  substance  in  the  blood  and  render  the  leucocytes 
still  more  active  than  before. 

It  is  said  that  this  treatment  has  proved  beneficial  in  almost 
all  varieties  of  local  tuberculosis,  and  although  I  have  no 
knowledge  of  it  having  been  used  in  mammary  tuberculosis, 
there  is  no  reason  to  doubt  that  it  would  do  good  in  this 
form  of  the  disease  as  well  as  in  others.  I  wish  to  state  dis- 
tinctly, however,  that  it  should  not  be  used  as  a  substitute  for 
operation,  which  has  been  proved  to  be  efficacious,  but  as  a 
supplement  to  operation,  with  the  view  of  hastening  recovery 
by  increasing  the  opsonic  power  of  the  blood.  I  am  also 
inclined  to  consider  it  applicable  to  cases  in  which  operation 
is  refused  and  injections  of  iodoform  fail  to  do  good. 

The  vaccine  used  is  the  New  Tuberculin  Koch  (bacilli  emul- 
sion) commonly  known  as  Tuberculin  R.  It  consists  of  the 
triturated  bodies  of  tubercle  bacilli  suspended  in  glycerin.  It 
should  be  administered  by  a  competent  laboratory  expert, 
who  is  required  to  make  frequent  estimations  of  the  opsonic 
power  of  the  blood,  so  that  the  injections  can  be  properly 


56  Diseases  of  the   Breast. 

timed  in  order  to  avoid  obtaining  an  accumulative  depressant 
effect  instead  of  the  desired  increase  in  the  opsonic  power. 
When  the  dose  which  will  increase  the  opsonic  index  is  deter- 
mined, it  is  administered  hypodermatically  whenever  the  blood 
shows  any  tendency  for  the  opsonic  power  to  fall.  It  is  not 
necessary  to  increase  the  dose  limit  further. 

Another  method  of  treatment  which  has  proved  of  value, 
especially  in  the  hands  of  its  originator,  is  Bier's  passive  hyper- 
emia. This  method  has  given  especially  good  results  in  all 
kinds  of  chronic  fistulae,  tuberculous  and  otherwise.  It  is 
applied  to  regions  like  the  breast  by  specially  devised  apparatus, 
that  for  the  breast  consisting  of  a  large  hemispherical  glass 
vessel,  slightly  larger  than  the  breast  itself.  In  the  dome  of 
the  vessel  is  a  round  aperture  with  a  glass  nipple  attachment. 
To  this  is  attached  a  rubber  tube  which  is  connected  with  a 
suction  pump. 

The  apparatus  is  placed  over  the  affected  breast  and  suffi- 
cient negative  pressure  created  by  the  pump  to  cause  a  red 
hyperemia,  not  allowing  the  skin  to  become  blue  or  pale. 
It  is  left  on  for  five  minutes,  then  removed  for  five  minutes, 
after  which  it  is  reapplied  for  another  five  minutes,  etc.  This 
alternation  is  continued  for  forty-five  minutes  daily.  It 
causes  a  hypernutrition  of  the  part  and  stimulates  all  repara- 
tive processes. 

Passive  hyperemia  might  be  advantageously  combined 
with  Wright's  vaccination  method,  for  it  is  asserted  that  in 
these  tuberculous  sinuses  the  serum  in  the  region  of  the  mor- 
bid process  has  a  lower  opsonic  index  than  in  the  remainder 
of  the  body.  After  several  treatments  with  the  Bier's  appa- 
ratus, the  local  opsonic  index  is  brought  up  to  the  standard  of 
the  general  index.  If  we  raise  the  general  index  above  the 
normal  we  may,  by  combining  the  two  methods  of  treatment, 
also  increase  the  local  index  above  the  normal  and  greatly 
hasten  the  healing  of  the  sinus. 


SYPHILIS. 

Syphilis  may,  affect  the  mammary  gland  in  its  primary, 
secondary,  or  tertiary  stage,  and  may  occur  in  either  sex, 
although  it  is  far  more  common  in  females  than  in  males. 
Fournier,  whose  experience  is  unrivaled,  had  seen  only  three 
cases  in  men  up  to  1897,  when  his  classical  work  on  extra- 
genital chancres  was  published. 

In  regard  to  the  frequency  of  primary  mammary  syphilis 
as  compared  with  other  extra-genital  forms  of  the  disease,  a 
series  of  cases  recently  reported  by  Ivanyi,  of  Buda  Pest, 
is  of  interest.  Out  of  138  cases  of  extra-genital  syphilis  he 
found  that  only  6,  or  4.34  percent,  were  of  mammary  origin. 
Thus  it  is  seen  that  primary  mammary  syphilis  is  rare. 

The  initial  lesion  of  syphilis  as  it  affects  the  female  breast 
is  most  common  in  nursing  women,  being  produced  by  inocula- 
tion with  the  syphilitic  virus  from  the  mouth  of  an  infant 
suffering  with  the  disease.  Infants  affected  with  hereditary 
syphilis  often  convey  the  disease  to  wet-nurses,  who  in  turn 
transmit  it  to  other  children  whom  they  suckle;  and  these 
infants  then  become  capable  of  disseminating  infection  among 
other  wet-nurses  to  whose  breasts  they  may  perchance  be  put. 

A  nurse  tainted  with  constitutional  syphilis  contracted 
through  sexual  intercourse  may  also  infect  a  nursling,  who 
of  course  becomes  an  immediate  source  of  contagion  to  all 
those  with  whom  it  comes  in  contact,  but  particularly  to  its 
mother  or  other  women  who  may  nurse  it.  Thus  it  is  seen 
that  a  single  syphilitic  infant  or  a  single  syphilitic  wet-nurse 
may  be  the  means  of  infecting  a  multitude  of  innocent  persons. 
Epidemics  of  syphilis  originating  in  this  manner  have  been  re- 
ported, especially  in  France  and  Italy,  and  many  households 

57 


58  Diseases  of  the  Breast. 

have  been  rendered  syphilitic  in  the  same  way,  even  when  the 
original  disseminator  of  the  disease  was  apprehended  and  pre- 
vented from  distributing  the  loathsome  malady  promiscuously. 

This  manner  of  conveying  syphilis  was  well  recognized  by 
Ambrose  Pare,  who  describes  an  instance  in  which  a  syphilitic 
wet-nurse  infected  an  infant,  who  in  turn  infected  its  mother, 
with  the  result  that  its  father  contracted  the  disease.  Later 
two  other  children  became  infected,  presumably  by  eating  or 
drinking  from  the  same  dishes  used  by  the  father. 

In  addition  to  this,  the  common  mode  of  infection  of  the 
breast,  there  are  cases  on  record  in  which  the  malady  has 
been  conveyed  through  the  diseased  mouth  of  a  syphilitic 
adult.  It  was  to  this  form  of  infection  that  Ricord  caustically 
applied  the  expression  "  contagion  par  nourrison  adulte" 

In  persons  of  uncleanly  and  careless  habits  infection  might 
easily  be  transmitted  through  the  medium  of  towels,  hand- 
kerchiefs, or  articles  of  wearing  apparel,  which  had  been  con- 
taminated with  the  syphilitic  virus.  Whether  such  cases  have 
actually  occurred  I  do  not  know,  but  the  possibility  of  their 
occurrence  is  worth  bearing  in  mind. 

One  or  both  breasts  may  be  infected  and  the  initial  lesion 
may  be  multiple.  Thus,  for  example,  Keyes  has  observed  a 
case  in  which  there  were  twelve  chancres,  eight  on  one  breast 
and  four  on  the  other. 

This  multiplicity  of  lesions  is  not  surprising  when  we  come 
to  consider  the  conditions  in  the  lactating  breast  favoring 
infection.  The  various  erosions  and  fissures  so  often  present 
serve  as  admirable  portals  of  entry  for  the  syphilitic  poison, 
and  the  repeated  applications  of  the  child  to  the  breast  furnish 
a  frequent  source  of  fresh  infection. 

In  regard  to  the  location  of  the  initial  lesion,  it  has  been 
found  that  the  most  common  site  is  at  the  junction  of  the 
nipple  and  areola,  although  it  may  be  situated  upon  the  nipple 
itself,  upon  any  part  of  the  areola,  or  upon  the  cutaneous 


Syphilis.  59 

surface  of  the  breast.     The  last  named  site,  however,  is  very- 
rare. 

Fournier,  who  has  had  the  opportunity  of  observing  incipient 
mammary  chancre  in  four  cases,  describes  three  different 
forms:  1,  a  very  minute  round  cutaneous  elevation,  smaller 
than  a  lentil;  2,  a  dark  red  cutaneous  elevation;  3,  a  cuta- 
neous elevation  the  center  of  which  soon  becomes  desquamated 
and  eroded,  and  is  smaller  than  the  head  of  a  pin.  This  form 
of  initial  lesion  looks  more  like  an  abrasion  than  anything 
else. 

The  fully  developed  mammary  chancre  may  be  incrusted 
or  open.  In  the  latter  instance  it  may  present  the  appear- 
ance of  a  fissure  or  show  signs  of  well-marked  ulceration. 
The  latter  form  is  not  uncommon.  Occasionally  mammary 
chancre  may  become  phagedenic,  particularly  in  debilitated 
women. 

Thus  it  is  seen  that  the  primary  lesion  is  often  atypical. 
This  circumstance  renders  diagnosis  difficult,  particularly 
in  the  early  stages  of  the  sore.  When  any  doubt  exists,  the 
safest  thing  to  do  is  to  consider  the  lesion  syphilitic  until  time 
proves  it  not  to  be.  By  so  doing  the  spread  of  contagion 
may  be  checked. 

Paget's  disease  may  resemble  an  ulcerating  chancre  in  some 
respects,  but  its  slower  evolution  and  the  absence  of  axillary 
involvement  serve  to  distinguish  it  from  the  latter. 

A  thorough  and  careful  examination  would  prevent  con- 
fusion of  a  phagedenic  chancre  with  malignant  disease.  Other 
signs  of  syphilis  would  be  found,  or  would  develop  while  the 
case  was  under  observation. 

Mammary  chancre  gives  rise  to  enlargement  of  the  axillary 
glands,  and  in  course  of  time  the  ordinary  secondary  signs  of 
syphilis  develop. 

Some  have  maintained  that  constitutional  syphilis  following 
mammary  chancre  is  often  more  severe  than  that  developing 


6o  Diseases  of  the   Breast. 

after  inoculation  through  other  portions  of  the  body.  These 
observers  evidently  overlook  the  fact  that  many  subjects  of 
mammary  chancre  are  ill-nourished,  overworked,  and  debilit- 
ated, so  that  they  are  unable  to  withstand  the  encroachment 
of  their  infection  as  well  as  the  more  fortunate  persons  in  the 
better  walks  of  life  who  contract  their  syphilis  in  the  more 
usual  way.  Certainly  there  is  no  reason  to  believe  that  syph- 
ilis following  a  mammary  chancre  would  be  more  violent  than 
that  developing  after  any  other  form  of  initial  lesion,  provided 
that  the  individual's  powers  of  resistance  are  not  below  par. 

In  addition  to  the  ordinary  cutaneous  eruption  of  secondary 
syphilis  which  may  appear  on  the  breast,  the  softness  of  the 
skin,  the  moisture,  and  the  friction  of  the  two  opposing  sur- 
faces at  the  junction  of  the  breast  and  thoracic  wall,  all  favor 
the  development  of  moist  syphilides,  particularly  in  women 
whose  breasts  are  pendulous  and  who  are  of  uncleanly  habits. 
These  lesions  may  appear  as  groups  of  papules,  or  as  spots 
of  various  size,  resembling  mucous  patches.  Occasionally 
the  latter  form  may  cover  the  entire  inferior  surface  of  the 
gland  or  even  extend  to  the  chest- wall. 

Papular  syphilides  and  mucous  patches  are  also  found 
on  the  areola  and  nipple. 

Tertiary  syphilis  may  affect  the  mammary  gland  in  the 
form  of  gummata,  diffuse  inflammation,  tubercles,  rupia  and 
ulcers.  Both  sexes  are  subject  to  this  stage  of  the  disease, 
although  it  is  more  frequently  seen  in  women  than  in  men. 

Gummata  may  occur  in  any  part  of  the  breast,  appearing 
as  hard,  circumscribed  tumors,  which  form  insidiously  and 
increase  in  size  slowly,  so  that  they  do  not  attract  much  atten- 
tion during  the  early  stages  of  their  evolution.  In  the  later 
stages,  however,  they  show  a  tendency  to  soften  and  break 
through  the  skin.  As  the  process  of  softening  advances  the 
tumors  become  adherent  to  the  skin,  which  assumes  a  dark 
congested  appearance  and  later  gives  way  to  allow  the  escape 


Syphilis.  61 

of  the  products  of  liquefaction  beneath.  At  this  period  the 
axillary  glands  are  found  to  be  enlarged. 

Such  softened  gummata  have  been  mistaken  for  cysts,  and 
their  true  nature  revealed  only  at  the  time  of  operation. 

In  their  early  stages  gummata  may  be  mistaken  for  benign 
tumors,  particularly  if  there  are  no  signs  of  syphilis  in  other 
parts  of  the  body.  Likewise  there  may  be  difficulty  in  separat- 
ing them  from  malignant  growths  after  they  have  become 
adherent  to  the  skin  and  enlargement  of  the  axillary  glands 
has  occurred.  Under  these  circumstances  a  careful  examina- 
tion for  other  signs  of  syphilis  and  interrogation  of  the  patient 
in  reference  to  a  previous  syphilitic  infection  may  prove  of  help 
in  making  a  differential  diagnosis.  A  history  of  previous 
nodules  or  masses  in  the  breast  which  have  disappeared 
without  treatment  is  suggestive  of  syphilis,  provided  that 
inflammatory  affections  can  be  excluded.  At  all  events  the 
progress  of  the  case  will  reveal  its  true  nature.  The  therapeutic 
test,  preferably  in  the  form  of  hypodermatic  injections  of 
mercury  bichloride  and  large  doses  of  iodides  internally, 
may  be  tried  in  doubtful  cases.  Gummata  usually  soften  and 
rupture  within  a  few  months  after  they  are  first  detected,  their 
course  thus  being  much  more  rapid  than  that  of  carcinomata. 

In  diffuse  syphilitic  inflammation  of  the  breast  a  portion  of  or 
perhaps  the  entire  gland  is  enlarged,  hard,  and  sometimes  pain- 
ful. This  form  of  mammary  syphilis  is  not  a  remote  manifes- 
tation of  the  disease,  but  usually  occurs  during  the  latter  part 
of  the  secondary  stage.  It  has  been  known  to  develop  shortly 
after  the  first  appearance  of  the  secondary  rash.  The  period 
of  its  incidence  thus  makes  diagnosis  comparatively  easy. 

As  considerable  evidence  has  been  accumulated  to  show  that 
the  spirocheta  or  spironema  pallida  may  be  the  specific  cause 
of  syphilis,  in  doubtful  cases  scrapings  from  the  lesions,  as 
well  as  the  tissue  juices  and  blood,  should  be  examined  for 
this   organism.     To   stain   for   the   spironema   in    coverglass 


62  Diseases  of  the   Breast. 

spreads,  the  scrapings  from  the  lesions  or  the  tissue  juices 
from  their  center  are  spread  thinly  over  the  glass  and  then 
dried  in  the  air,  after  which  they  are  fixed  for  ten  minutes  in 
absolute  alcohol  and  then  treated  with  the  following  modifi- 
cation of  Giemsa's  azur-eosin  stain  freshly  prepared: — (i) 
12  parts  of  Giemsa's  eosin  solution  (2.5  cc,  1  percent  eosin 
solution  in  500  cc.  of  water) ;  (2)  3  parts  azur  I  (1-1000  water) ; 
(3)  3  parts  azur  II  (0.8-1000  water).  It  is  left  in  this  stain 
for  sixteen  to  twenty-four  hours,  washed  for  a  short  time  in 
water,  dried,  and  examined  in  cedar  oil. 

The  organism  can  be  recovered  from  the  blood  by  Noegerath 
and  Staehlin's  method,  which  consists  in  taking  1  cc.  of  blood 
and  10  cc  of  a  3  percent  solution  of  acetic  acid,  mixing  them, 
centrifuging,  and  examining  the  deposit. 

The  spironema  is  a  very  delicate  spiral  organism,  weakly  re- 
fractile,  having  rlagella  at  both  ends,  and  measuring  from  4  to  20 
microns  in  breadth.     The  spirals  are  very  narrow  and  regular. 

In  regard  to  the  treatment  of  mammary  syphilis  there  is 
little  to  be  said.  The  usual  antisyphilitic  treatment  with 
mercury  and  the  iodides  is  to  be  employed,  and  as  a  rule 
causes  the  lesions  to  yield  rapidly.  Chancres  of  the  breast 
require  little  treatment  other  than  cleanliness.  If  of  the 
ulcerative  type  they  may  be  dusted  with  calomel  and  bismuth 
subnitrate,  equal  parts,  whereupon  they  will  soon  become 
healthy  and  heal. 

Gummata  yield  readily  to  mixed  treatment,  or  to  inunctions 
of  mercury  and  large  doses  of  the  iodides  internally. 

In  poorly  nourished,  debilitated  women,  every  effort  should 
be  made  to  build  up  the  general  health  by  means  of  generous 
diet  and  the  use  of  bitter  tonics,  or  iron  and  arsenic,  in  addition 
to  the  use  of  specific  medication. 

It  is  hardly  necessary  to  say  that  the  most  careful  prophy- 
lactic measures  should  be  taken  to  prevent  the  propagation 
of  the  disease  by  women  thus  affected. 


ACTINOMYCOSIS. 

Actinomycosis  of  the  breast  is  rare,  although  a  few  authentic 
cases  are  on  record.  The  disease  may  be  either  primary 
or  secondary,  infection  occurring  from  without  through  a 
wound  or  abrasion,  or  extending  from  other  organs  of  the 
body,  for  example,  the  lungs  or  pleura. 

The  primary  wound  may  heal  and  actinomycosis  break 
out  later. 

The  invading  parasites  set  up  inflammation,  as  a  result 
of  which  the  skin  over  the  gland  becomes  reddened  and 
breaks  down,  sinuses  form,  and  pus  containing  the  actinomyces 
is  discharged.  The  substance  of  the  gland  may  be  destroyed, 
and  in  cases  in  which  the  infection  occurs  from  without  the 
pectoral  muscles  may  be  invaded  and  even  the  ribs  attacked. 
Metastases  may  also  occur. 

Mammary  actinomycosis  is  very  rebellious  to  treatment, 
and  the  most  active  measures  should  always  be  adopted  to 
combat  its  inroads. 

The  greatest  danger  is  to  be  apprehended  from  the  devel- 
opment of  metastases. 

The  only  rational  procedure  is  to  remove  all  the  diseased 
tissue,  cutting  well  into  the  healthy  portion  of  the  gland. 
It  may  be  necessary  to  amputate  the  breast.  Large  doses 
of  potassium  iodide  should  be  given. 

When  the  disease  is  secondary  the  chances  of  cure  are 
less  favorable  than  in  the  primary  form.  In  a  secondary  case 
reported  by  Nelaton,  however,  the  patient  overcame  the 
disease  to  the  extent  of  regaining  her  general  health,  and  this 
despite  the  fact  that  a  periodic  discharge  of  pus  containing 
actinomyces  occurred  not  only  from  a  small  sinus  in  the 
breast,  but  also  from  others  in  the  lumbar  region. 

63 


CYSTS. 

Much  confusion  has  prevailed  in  regard  to  the  etiology 
and  pathology  of  mammary  cysts.  First  of  all  it  is  necessary 
to  distinguish  true  cysts  from  neoplasms  which  have  under- 
gone cystic  degeneration,  and  it  is  only  the  former  which  will 
be  considered  here.  The  latter  will  be  discussed  in  connec- 
tion with  tumors. 

We  recognize  the  following  varieties  of  mammary  cysts: 
single  retention  cyst,  lymphatic  cyst,  general  cystic  disease, 
galactocele,  echinococcus-cyst,  and  dermoid  cyst.  In  ad- 
dition to  these  varieties  sebaceous  cysts  of  the  areola  have 
occasionally  been  observed. 

Single  Retention  Cyst. 

This  form  of  mammary  cyst,  which  is  not  uncommon, 
is  due  to  occlusion  of  a  galactophorous  duct  by  the  products 
of  inflammation.  Thus  previous  disease  of  the  breast  or  injury 
may  alike  be  responsible  for  the  obstruction  of  the  lumen  of 
the  duct,  which  leads  to  dilatation  of  the  remaining  free  por- 
tion. 

These  cysts  vary  in  size,  some  being  no  larger  than  a  marble, 
while  others  are  as  big  as  a  small  orange.  They  do  not  differ 
from  cysts  formed  in  other  glandular  organs  by  occlusion  of 
the  excretory  ducts,  being  of  comparatively  rapid  formation, 
and  appearing  in  the  breast  as  regular  round  or  oval  swellings 
of  elastic  consistency.  Fluctuation  may  be  plainly  detected 
in  most  cases.  Pain,  tenderness,  and  involvement  of  the 
axillary  glands  are  absent. 

The  fluid  contained  in  these  cysts  is  serous  and  varies  in 
color  from  light  yellow  to  reddish  or  brown.     Discoloration 

64 


Cysts. 


65 


of  the  fluid  is  probably  due  to  solution  of  blood  coloring  matter 
from  occluded  vessels  in  the  wall  of  the  cyst. 

The  wall  is  thin  and  the  surrounding  tissue  is  normal  in 
every  respect. 

Treatment  consists  in  dissecting  the  cyst  out  in  its  entirety. 


Fig.  13. — Large  retention  cyst  of  left  breast. 


Lymphatic  Cyst. 

This  form  of  cyst,  which  has  been  described  by  Birkett 
and  later  more  carefully  studied  by  Labbe  and  Coyne,  is 
due  to  the  accumulation  and  retention  of  fluid  in  the  lymph- 
spaces  in  the  connective  tissue  of  the  mamma.  Lymphatic 
cysts  may  be  either  single  or  multiple  and  occur  as  firm,  hard 
masses  of  round  or  oval  shape,  being  usually  about  the  size 

5 


66  Diseases  of  the   Breast. 

of  a  hazel-nut.  Fluctuation  is  absent  as  a  rule,  and  neither 
pain  nor  tenderness  to  pressure  are  present.  The  axillary 
glands  are  not  involved. 

The  contents  of  these  cysts  is  clear,  pale  yellow  fluid,  and 
the  wall  is  lined  with  a  single  layer  of  flat  epithelial  cells. 

Treatment  consists  in  dissecting  out  the  cyst  exactly  as  is 
done  in  single  retention  cyst. 

General  Cystic  Disease. 

Of  all  the  diseases  to  which  the  mammary  gland  is  subject 
there  is  not  one  concerning  which  so  much  confusion  has 
prevailed  as  this  one,  nor  any  to  which  such  a  variety  of  names 
has  been  applied.  Although  multiple  cyst-formation  in  the 
breast  has  long  been  recognized,  its  pathology  has  been  sur- 
rounded with  obscurity,  and  various  theories  have  been  for- 
mulated in  explanation  of  its  cause  and  development. 

Sir  Astley  Cooper  recognized  this  condition,  but  erroneously 
called  it  hydatid  disease.  Sir  Benjamin  Brodie  also  gave 
a  good  description  of  it.  He  considered  it  to  be  due  to  dilata- 
tion of  the  galactophorous  ducts.  It  is  most  interesting  to 
note  that  this  acute  observer  plainly  recognized  the  pro- 
gressive nature  of  the  affection,  and  called  attention  to  the 
fact  that  it  assumes  a  totally  new  character  as  it  proceeds. 
This  observation  is  of  particular  interest  in  the  light  of  our 
present  knowledge,  and  especially  as  concerns  the  views  to  be 
enunciated  here  relative  to  the  pathogenesis  and  nature  of 
the  disease. 

Despite  the  contribution  of  these  two  surgeons  little  atten- 
tion was  given  to  the  disease  until  i860,  when  Reclus  published 
an  account  of  it,  calling  attention  to  the  frequency  with  which 
both  breasts  are  affected,  the  hardness  of  the  diseased  areas, 
and  the  absence  of  a  well-defined  tumor.  He  made  further 
contributions  in  the  years  1883  and  1887,  and  maintained 
that  the  disease  was  due  to  proliferation  of  the  glandular 


PLATE  IV. 


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Cysts.  69 

epithelium.  Although  Reclus  gave  it  the  name  of  intra- 
acinous  cystic  epithelioma,  it  has  frequently  been  called  Reclus' 
disease,  or  simply  cystic  disease  of  the  breast. 

Following  Reclus'  contributions  numerous  investigations 
were  carried  on,  principally  by  French  and  German  surgeons 
and  pathologists,  with  the  result  that  other  theories  in  regard 
to  the  origin  and  nature  of  the  disease  were  advanced. 

Tillaux  and  Phocas  described  the  same  condition  under  the 
name  of  maladie  noueuse,  and  asserted  that  it  was  a  chronic 
mastitis  with  formation  of  fibrous  tissue.  Rochard  main- 
tained that  the  condition  was  merely  the  expression  of  any 
one  of  a  number  of  different  pathological  processes.  Many 
differed  from  Reclus  in  regard  to  the  close  relation  of  the 
disease  to  carcinoma,  notably  Quenu  and  Verneuil.  Others 
advanced  the  theory  that  the  process  was  primarily  inflam- 
matory. In  Germany  Schimmelbusch  made  a  study  of  the 
subject  with  the  result  that  he  decided  the  cysts  were  due  to 
new  formation,  and  added  the  name  of  cystadenoma  to  the 
list  of  those  already  in  vogue.  To  increase  the  multiplicity 
of  terms  Sasse  proposed  the  name  of  epithelial  polycystoma, 
holding  that  the  term  cystadenoma  was  inadequate,  inasmuch 
as  the  process  is  much  more  diffuse  than  an  ordinary  neoplasm, 
and  is  also  especially  characterized  by  epithelial  formation. 

In  the  article  on  chronic  mastitis  it  was  stated  that  in 
the  diffuse  form  of  that  disease  multiple  cysts  of  the  most 
various  size  were  found  dispersed  throughout  the  mammary 
tissues,  and  it  was  furthermore  stated  that  they  were  reten- 
tive cysts  pure  and  simple,  being  due  to  the  occlusion  of  the 
ducts  by  thickened  fibrous  tissue.  Moreover,  attention  was 
called  to  the  diversity  of  opinion  which  existed  in  regard  to 
the  location  of  the  primary  changes  which  occur.  The  con- 
dition of  the  epithelium  within  these  cysts  was  also  mentioned, 
it  being  stated  that  in  some,  particularly  the  smaller  ones,  it 
was  normal,  whereas  in  others  proliferation  could  be  plainly 


70  Diseases  of  the   Breast. 

seen.  The  views  set  forth  concerning  the  etiology  of  diffuse 
chronic  mastitis  will  also  be  remembered.  In  brief  it  was 
stated  that  deviations  from  the  normal  functional  activity 
of  the  gland,  accompanied  as  they  must  be  by  alterations  of 
structure,  and  particularly  the  changes  and  aberrations  to  which 
it  is  subject  during  pregnancy,  lactation,  and  the  period  of 
involution,  were  responsible  for  the  abnormal  condition  then 
under  discussion. 

What  I  wish  to  declare  in  this  place  is  that  I  believe  chronic 
diffuse  mastitis  with  cyst-formation,  and  general  cystic  disease 
of  the  breast,  to  be  one  and  the  same  disease.  The  only 
difference  which  exists  is  a  difference  in  degree,  and  the  reason 
for  describing  the  stage  in  which  cyst-formation  reaches  its 
height  apart  from  the  earlier  stages  of  the  disease  is  to  better 
emphasize  the  belief  here  expressed  as  to  their  identity,  and 
also  to  follow  a  nomenclature  which  has  long  been  familiar 
to  English  readers.  As  far  as  scientific  accuracy  is  con- 
cerned, it  would  no  doubt  be  better  to  call  the  disease  fibrous 
and  glandular  hyperplasia  with  retention  cysts,  a  term  de- 
vised by  Dr.  W.  F.  Whitney,  of  Boston.  The  term  abnormal 
involution,  used  by  Dr.  Warren,  is  also  an  appropriate  one. 

As  the  process  of  cyst-formation  advances  and  the  cysts 
become  larger,  a  stimulus  to  the  proliferation  of  the  epithelium 
within  the  affected  ducts  and  acini  is  supplied,  and  in  some 
cases  this  proliferation  is  so  pronounced  as  to  result  in  the 
formation  of  distinct  papillary  out-growths  from  the  cyst-wall. 
It  is  this  circumstance,  no  doubt,  which  has  lead  some  to  con- 
sider cysts  presenting  this  appearance  as  true  neoplasms. 
In  addition  to  this  form  of  proliferation  Greenough  and 
Hartwell  have  described  what  they  call  adenomatous  prolifera- 
tion, a  condition  in  which  the  papillary  outgrowths  coalesce,  so 
that  when  a  section  of  the  tissue  is  examined  under  the  micro- 
scope it  appears  as  though  there  is  a  space  filled  with  epithe- 
lium in  which  an  occasional  open  gland  can  be  detected. 


PLATE  V. 


General  cystic  disease  (abnormal  involution).     Microscopic  appearances. 
Note  the  dilatations. 


Cysts. 


73 


Warren  has  called  attention  to  the  fact  that  there  may  be 
an  increase  in  the  number  of  the  acini  in  this  disease,  and 
that  there  is  usually  a  marked  associated  proliferation  of  the 
epithelial  cells  in  the  ducts. 

In  a  certain  proportion  of  cases  of  advanced  cystic  disease 
with  proliferation  of  epithelium  the  morbid  process  may  advance 
to  malignancy.     Greenough  and   Hartwell  found   associated 


•:  ' 


. 


■ 


. 


%£V  ; 


0&*  \  ^m^ut 


9mt 


Fig.   14. — Abnormal  involution.     Acinal  type  of  epithelial  proliferation. 

carcinoma  in  10  percent  of  the  cases  which  they  studied  and 
Warren  found  it  in  13  percent  of  his  series. 

In  regard  to  the  symptoms  and  signs  of  this  disease,  the 
remarks  made  under  the  description  of  chronic  diffuse  mastitis 
are  applicable.  As  the  cysts  increase  in  size  alterations  in  their 
contents,  as  well  as  changes  in  their  wall  often  take  place. 
Thus  the  fluid  within  them  may  become  turbid  or  discolored, 
as  is  the  case  in  single  retention  cyst. 

Treatment  consists  in  removing  all  the  diseased  mammary 


74  Diseases  of  the   Breast. 

tissue.  In  cases  where  a  portion  of  the  gland  is  comparatively 
free  from  disease  I  have  of  late  practised  plastic  resection  of  the 
breast,  according  to  the  method  of  Warren,  and  find  that  it  gives 
entirely  satisfactory  results. 

In  these  cases,  however,  I  consider  it  of  the  utmost  importance 
to  have  a  competent  microscopist  present  at  the  operation,  so 
that  a  portion  or  portions  of  the  diseased  tissue  may  be  examined 
at  once  with  a  view  to  determining  whether  any  signs  of  car- 
cinomatous degeneration  are  present.  If  so,  the  breast  is  re- 
moved, together  with  the  pectoral  muscles  and  axillary  glands. 
I  consider  it  just  as  important  to  take  this  precaution  in  the 
class  of  cases  now  under  discussion  as  in  cases  of  tumors  of 
doubtful  nature.  The  extra  time  required  for  the  microscopic 
examination  is  well  repaid  by  the  additional  light  which  it 
may  throw  upon  the  character  of  the  disease.  In  cases  where 
the  entire  gland  is  riddled  with  cysts  I  invariably  amputate 
the  breast. 

Galactocele. 

By  the  term  galactocele  is  understood  a  mammary  cyst 
the  contents  of  which  is  milk  or  some  product  of  milk.  In  some 
such  cysts  the  contents  differs  in  no  wise  from  the  milk  which 
is  normally  secreted  by  the  breast  during  lactation,  but  in  others 
it  is  thick  and  creamy  or  even  caseous.  Occasionally  a  caseous 
mass  is  found  floating  in  milk-like  or  serous  fluid.  It  is  in 
recent  galactoceles  that  the  contents  most  closely  resembles 
normal  milk,  whilst  in  those  of  long  duration  changes  are  apt 
to  take  place  in  the  fluid  which  result  in  its  assuming  one  of 
the  characteristics  just  mentioned.  Sometimes,  too,  the  con- 
tents resembles  colostrum. 

From  these  remarks  it  is  seen  that  galactocele  is  an  entirely 
different  condition  than  engorgement  of  the  breast  with  milk. 

This  disease  is  one  of  the  rarest  to  which  the  breast  is  subject. 
I  have  seen  but  a  single  case,  and  Keen,  who  states  that  he  has 


PLATE  VI. 


Fig.  i. — Abnormal  involution.    Microscopic  appearances.  Papillary 
and  adenomatous  types  of  epithelial  proliferation.     (Warren.) 


•  --**. 


■'  ~.  '. 


--^  -^^^kfJ'J^^^' 


Fig.  2. — Abnormal  involution  and  adenocarcinoma.     Microscopic 
appearances.     (Warren.) 


Cysts.  77 

amputated  five  hundred  breasts  and  seen  three  hundred  others 
which  were  diseased,  has  likewise  seen  only  one  case. 

Although  galactocele  most  frequently  develops  during  lacta- 
tion or  just  after  the  child  is  weaned,  it  may  occur  during 
pregnancy,  and  a  few  cases  have  also  been  observed  in  women 
who  have  never  borne  nor  suckled  children.  My  case  was  in  a 
woman  who  had  never  been  pregnant. 

It  is  usually  stated  that  galactocele  is  a  retention  cyst,  and 
while  it  is  true  that  partial  or  complete  occlusion  of  a  milk-duct 
in  the  lactating  breast,  from  whatever  cause  arising,  would  be 
likely  to  be  followed  by  a  retention  of  the  secretion  of  the  gland, 
the  fact  that  galactocele  occurs  in  women  whose  breasts  have 
never  secreted  milk  leads  me  to  believe  that  the  primary  cause  of 
the  formation  of  these  cysts  is  to  be  found  in  changes  in  the  epi- 
thelial lining  of  the  galactophorous  ducts,  as  a  result  of  which 
alterations  take  place  that  lead  to  dilatation  of  the  ducts. 
Whether  these  changes  in  the  activity  of  the  epithelium  lead  to 
the  formation  of  vegetations  which  partly  occlude  the  duct,  as 
is  maintained  by  Labbe  and  Coyne,  or  whether  dilatation  occurs 
irrespective  of  obstruction,  I  will  not  presume  to  say.  At  all 
events  endocanalicular  changes  afford  a  plausible  explanation 
for  the  occurrence  of  those  cases  which  have  been  observed  in 
women  whose  breasts  have  never  secreted  milk. 

It  would  seem  that  traumatism  is  a  factor  of  considerable 
importance  in  the  production  of  galactocele,  as  a  history  of 
blows  and  other  injuries  to  the  breast  has  been  given  in  a  num- 
ber of  the  recorded  cases.  In  some  of  these  cases,  however, 
the  injury  was  received  so  long  before  the  development  of  the 
galactocele  that  it  is  difficult  to  trace  any  causative  relation 
between  the  two,  unless  it  be  assumed  that  the  traumatism 
gave  rise  to  alterations  in  the  tissues  which  later,  particularly 
during  lactation,  resulted  in  the  formation  of  the  galactocele. 
In  this  case  it  would  be  reasonable  to  assume  either  that  the 
epithelium  of  the  ducts  had  undergone  alterations,  or  that  as  a 


78  Diseases  of  the   Breast. 

result  of  inflammation  in  the  interstitial  tissue  compression  of 
the  ducts  had  been  effected,  so  that  free  outlet  of  the  milk  se- 
creted later  could  not  take  place. 

It  is  evident  that  the  ideas  here  advanced  concerning  the 
etiology  of  galatocele  are  purely  conjectural,  and  'it  must  be 
admitted  that  the  cause  of  this  form  of  mammary  cyst,  in  com- 
mon with  the  causes  of  many  other  affections  to  which  the  mam- 
mary gland  is  subject,  are  very  obscure.  Although  little 
definite  is  known  about  them  at  present,  it  is  to  be  hoped  that 
further  study  will  result  in  a  better  understanding  of  the  manner 
of  their  production. 

In  regard  to  the  appearance  of  galatocele,  it  may  be  stated 
that  it  usually  occurs  as  a  single  rounded  swelling  situated, 
as  a  rule,  in  the  external  segment  of  the  breast.  The  size  of 
the  swelling  is  variable.  At  first  it  is  small,  but  as  time  goes 
on  it  may  attain  a  very  large  size.  The  average  size  is  probably 
about  that  of  a  medium-sized  orange.  It  is  slow  in  develop- 
ing and  may  retain  its  original  dimensions  for  a  very  long  period 
of  time.  It  has  been  observed  that  lactation  causes  a  rapid  in- 
crease in  the  size  of  the  cyst. 

When  the  contents  of  a  galactocele  is  fluid  fluctuation  can 
usually  be  obtained,  and  pressure  upon  the  swelling  causes 
fluid  to  exude  from  the  nipple.  The  latter  circumstance  shows 
that  there  is  not  complete  occlusion  of  the  duct.  Galatocele 
is  not  painful  and  is  not  adherent  to  the  skin  nor  to  the 
parts  beneath  it.  Its  consistency  naturally  varies  with  the 
nature  of  its  contents.  A  sign  to  which  Gross  called  attention 
is  pitting  upon  pressure.  When  this  phenomenon  is  present 
it  is  probable  that  the  contents  is  thick  or  caseous.  Neither 
this  sign  nor  fluctuation  are  always  obtainable.  Concerning 
the  former  Delbet  states  that  in  the  absence  of  edema  it  is 
almost  pathognomonic. 

Suppuration  has  been  known  to  occur  in  a  galactocele,  and 
ulcerations  have  been  found  upon  the  internal  surface  of  its 


Cysts.  79 

walls.  In  my  case  the  breast  was  examined  microscopically  by 
Dr.  McFarland,  who  found  that  the  tissue  surrounding  the  cysts 
was  the  site  of  a  marked  interstitial  mastitis.  Similar  changes 
were  found  by  Coplin  and  Ellis,  who  examined  the  breast  in 
Dr.  Keen's  case.  They  state  that  the  most  conspicuous  change 
was  "a  marked  periacinous  infiltration  of  mononuclear  cells, 
nearly  all  of  whicli  were  of  the  small  round  variety." 

In  regard  to  diagnosis  it  may  be  stated  that  any  fluctuating 
tumor  developing  suddenly  in  the  breast  of  a  woman  who  is 
nursing  a  child  is  probably  a  galactocele.  Pitting  upon  pres- 
sure likewise  is  good  evidence  in  favor  of  galactocele,  as  has 
already  been  stated.  In  other  cases  where  the  cyst  has  been  of 
long  duration  or  developed  irrespective  of  lactation,  diagnosis 
will  not  be  so  easy,  and  its  nature  may  not  be  suspected  until 
incision  is  made. 

The  proper  treatment  of  galactocele  is  enucleation  of  the 
cyst  and  excision  of  the  surrounding  tissue.  Simple  incision 
and  evacuation  of  the  contents  is  not  satisfactory,  as  the  sac 
is  likely  to  fill  up  again.  Puncture  is  mentioned  solely  to  con- 
demn it. 

Hydatid  Cysts. 

The  mammary  gland  is  occasionally  though  very  rarely 
attacked  by  hydatid  disease.  In  comparison  with  other  dis- 
eases of  the  breast  hydatid  disease  is  of  little  importance  on 
account  of  the  rarity  with  which  it  occurs.  In  1,897  cases  of 
hydatid  disease  collected  from  various  sources  by  John  D. 
Thomas  only  20  affected  the  breast,  an  incidence  of  hardly 
more  than  1  percent.  When  the  rarity  of  hydatid  disease  itself 
is  considered,  the  low  percentage  of  the  mammary  form  shows 
how  rare  it  is  in  comparison  with  other  affections  of  the  breast. 

In  regard  to  the  etiology  of  mammary  hydatid  disease  nothing 
positive  is  known.  How  the  embryos  of  the  parasite  reach  the 
mammary  tissues  cannot  be  positively  stated,  but  it  is  probable 


80  Diseases  of  the   Breast. 

that  in  the  primary  cases  they  gain  access  through  the  blood- 
stream. 

The  breast  may,  however,  be  invaded  secondarily  from 
contiguous  structures,  notably  from  the  great  pectoral  muscle. 

So  far  as  I  have  been  able  to  determine  hydatid  cyst  of  the 
breast  has  occurred  only  in  women.  It  may  affect  any  portion 
of  the  gland. 

Hydatid  cyst  of  the  breast  begins  as  a  small,  hard,  distinctly 
circumscribed  swelling,  which  is  freely  movable  on  the  parts 
subjacent  to  it.  This  swelling  increases  in  size  very  slowly 
and  may  remain  stationary  for  months  or  years.  As  a  rule 
the  cyst  does  not  attain  a  very  large  size,  probably  not  being 
any  bigger  than  an  orange  in  the  majority  of  cases.  In  a  case 
reported  by  Berard,  however,  it  attained  a  volume  twice  as  great 
as  that  of  the  other  breast. 

It  has  been  known  to  grow  rapidly  after  injury.  This  hard, 
firm  consistence  is  usually  maintained  after  the  cyst  has  become 
of  a  considerable  size,  although  in  some  cases  fluctuation  has 
been  detected.  The  latter  phenomenon,  however,  has  been 
observed  only  in  large  cysts. 

The  wall  of  the  cyst,  which  consists  of  two  distinct  layers, 
is  apt  to  become  inflamed  and  suppurate,  with  the  result  that 
the  cyst  becomes  adherent  to  the  skin  and  finally  breaks  through 
it,  discharging  pus  and  the  hydatid  membranes  and  hooklets. 
The  axillary  glands  may  also  become  enlarged. 

It  is  in  these  later  stages,  too,  that  the  breast  becomes  pain- 
ful. It  is  common  for  these  degenerative  changes  to  take  place 
in  hydatid  cysts  of  the  breast  the  same  as  in  those  in  other  parts 
of  the  body.  In  twenty-four  cases  studied  by  R.  G.  LeConte 
the  contents  of  the  cyst  showed  changes  from  its  normal  limpid 
character  in  eight,  or  a  percentage  of  thirty-three  and  a  third. 

A  very  interesting  case  of  hydatid  cyst  of  the  breast  was 
operated  on  by  Dr.  LeConte,  in  1899,  at  the  Pennsylvania 
Hospital.     It  occurred  in  a  young  colored  woman,  aged  twenty- 


Cysts.  81 

seven  years,  who  had  spent  all  her  life  in  Philadelphia  and  the 
neighboring  city  of  Camden.  The  tumor  was  of  four  years' 
duration.  For  two  years  it  remained  of  about  the  same  size, 
but  began  to  grow  rapidly  after  an  injury  to  the  breast.  From 
twelve  to  fifteen  ounces  of  pus  escaped  when  the  mass  was 
opened.  This  pus  contained  large  numbers  of  hydatid  hook- 
lets. 

LeConte  believes  this  case  to  be  the  first  one  reported  in 
America.  A  search  through  the  literature  failed  to  show  any 
others  reported  in  this  country  before  or  since. 

Diagnosis  is  very  difficult,  as  these  cysts  closely  resemble 
benign  growths  as  regards  both  consistency  and  size,  as  well 
as  their  manner  of  evolution. 

Suppurating  hydatid  may  be  mistaken  for  an  abscess. 
Puncture  of  the  cyst  will  reveal  its  nature,  but  this  is  likely  to 
be  practised  only  when  suspicion  exists  that  one  is  dealing  with 
a  hydatid.  In  most  cases  the  diagnosis  will  be  made  only  upon 
operation. 

Treatment  consists  in  dissecting  out  the  cyst  when  possible, 
or  if  it  should  be  so  large  as  to  have  destroyed  much  of  the 
glandular  substance,  in  partly  or  completely  amputating  the 
breast.     Suppurating  hydatid  should  be  treated  as  an  abscess. 

/  Dermoid  Cysts. 

Dermoid  cysts  of  the  mammary  gland  are  so  rare  that  they 
require  simply  to  be  mentioned.  There  are  very  few  cases 
recorded  in  literature.  These  cysts  are,  of  course,  always  of 
congenital  origin,  although  they  may  be  so  small  as  to  escape 
detection  until  they  suddenly  begin  to  grow,  perhaps  late  in 
life,  and  then  first  attract  the  attention  of  the  patient. 

In  addition  to  dermoid  cysts  in  the  substance  of  the  gland, 
others  originating  from  the  sternum  and  encroaching  upon  the 
tissues  of  the  breast  have  been  reported. 

Diagnosis  is  difficult  and  in  the  majority  of  cases  will  be  made 


82  Diseases  of  the   Breast. 

only  at  the  time  of  operation.     Treatment  consists  in  excision 
of  the  cyst. 

Sebaceous  Cysts. 

Sebaceous  cysts  are  occasionally  met  with  around  the  nipple, 
originating  for  the  most  part  in  the  glands  of  Montgomery, 
although  they  may  occur  in  any  portion  of  the  integument  of 
the  breast.  They  are  usually  small,  but  in  some  instances  have 
been  known  to  attain  the  size  of  an  egg  or  even  become  larger. 
Increase  in  size,  however,  takes  place  slowly  and  the  cysts  may 
remain  stationary  for  long  periods  of  time.  These  cysts  usually 
give  rise  to  no  symptoms,  being  painless  and  non-sensitive  to 
touch.     They  may,  however,  become  inflamed. 

I  recently  removed  one  of  these  cysts  from  the  breast  of  a 
young  colored  woman.  She  first  noticed  it  about  four  months 
previous  to  the  time  of  operation.  It  constantly  increased  in 
size,  and  for  two  weeks  before  operation  had  caused  more  or 
less  dull  aching  pain,  and  occasionally  sharp  shooting  pains. 
Treatment  consists  in  dissecting  the  cyst  out  in  its  entirety, 
taking  care  not  to  rupture  the  sac. 


DIFFUSE  HYPERTROPHY. 

This  is  a  very  rare  affection  in  which  the  breasts  increase 
abnormally  in  size  either  at  puberty  or  during  pregnancy. 
Its  rarity  is  well  shown  by  the  fact  that  in  1902  Kirchheim  was 
able  to  collect  only  forty-two  authentic  cases  from  literature. 

The  disease  has  been  carefully  studied  by  this  author  and 
also  by  Schussler  and  Delbet,  and  it  is  from  their  works  that 
much  of  the  material  for  this  article  has  been  taken.  The 
great  rarity  of  the  affection  makes  it  necessary  for  a  collective 
investigation  to  be  made  in  order  that  any  definite  conclusions 
can  be  formed  in  regard  to  its  nature,  symptoms  and  course. 

In  regard  to  the  etiology  of  the  disease,  it  may  be  stated  that 
nothing  is  known  other  than  that  puberty  and  pregnancy  exert 
a  causative  influence.  Disturbances  of  the  pelvic  organs  are 
often  associated,  but  it  cannot  be  logically  maintained  that  they 
are  causative.  The  mere  circumstance  that  the  menses  fail  to 
appear  or  suddenly  become  arrested,  or  the  fact  that  ovarian 
enlargement  exists  simultaneously  with  the  mammary  disease, 
cannot  be  ri^htlv  construed  to  mean  that  the  latter  trouble  is 
dependent  upon  the  former. 

Among  other  conditions  to  which  causative  influence  has 
from  time  to  time  been  attributed  may  be  mentioned  irrita- 
tion, injury,  cold,  and  celibacy.  These,  however,  are  to  be 
considered  as  purely  accidental  conditions  which  have  no 
bearing  whatsoever  upon  the  development  of  the  disease. 

It  has  also  been  stated  that  race  and  climate  are  etiological 
factors,  but  the  researches  of  Kirchheim  tend  to  show  that  such 
is  not  the  case.  It  is  doubtful,  too,  as  to  whether  heredity 
plays  as  important  role,  although  Rousseau  mentions  the  case 
of  a  woman  whose  sisters  and  nieces  had  exceedingly  large 

83 


84  Diseases  of  the   Breast. 

breasts,  and  states  that  one  of  the  sisters  had  an  abnormal  en- 
largement of  the  breasts  during  pregnancy.  Pflanz  also  relates 
a  case  in  which  an  uncle  of  the  patient  had  abnormally  large 
breasts.  These  data,  however,  are  too  meagre  to  permit  the 
formation  of  any  inferences. 

In  regard  to  the  morbid  anatomy  of  this  affection,  it  should 
first  of  all  be  stated  that  there  seems  to  be  a  difference  between 
those  cases  occurring  at  or  about  the  time  of  puberty  and  those 
which  develop  during  pregnancy.  In  the  former  class  of  cases 
the  investigations  of  Labarraque,  Bartel,  Schussler,  and  Kirch- 
heim  seem  to  show  that  the  morbid  process  is  essentially  a 
diffuse  fibromatous  overgrowth.  In  those  occurring  in  preg- 
nancy there  is  a  marked  increase  in  the  glandular  elements. 
In  one  such  case  recently  studied  by  Deibel  glandular  structure 
predominated. 

The  subcutaneous  fat  over  the  breast  frequently  disappears, 
a  circumstance  which  is  probably  due  to  the  pressure  exerted 
upon  it  by  the  new  tissue. 

The  symptoms  as  well  as  the  morbid  anatomy  vary  according 
as  the  disease  develops  in  association  with  or  irrespective  of 
pregnancy.  It  has  been  observed  that  the  onset  is  more  sudden 
and  the  development  more  rapid  in  those  cases  occurring  in 
pregnant  women  than  in  those  occurring  in  the  non-pregnant. 
Thus,  for  example,  in  a  case  reported  by  Delfis  the  breasts  of  a 
pregnant  woman  became  so  hypertrophied  that  they  rested  upon 
her  thighs  when  she  assumed  the  sitting  posture,  and  this  abnor- 
mal increase  took  place  entirely  during  the  period  of  gestation, 
the  breasts  before  having  been  entirely  normal.  Esterle  has 
reported  another  case  in  which  they  attained  the  weight  of 
twenty-six  to  thirty  pounds  in  three  and  one-half  months. 

Two  stages  of  the  disease  are  usually  described.  In  the  first 
stage  the  normal  contour  of  the  breasts  is  preserved,  the  only 
change  being  an  increase  in  their  size.  The  skin  is  not  altered, 
and  the  chief  subjective  symptom  is  uneasiness,  or  perhaps 


Diffuse  Hypertrophy.  85 

slight  interference  with  respiration,  owing  to  the  increased 
weight  of  the  organs.  Pain  may  or  may  not  be  present  in  this 
stage.  Some  authors  state  that  it  is  absent,  others  that  it  is 
present.  From  a  study  of  the  literature  it  is  found  that  the 
symptom  occurs  in  some  cases  and  is  absent  in  others. 


Fig.  15. — Diffuse  hypertrophy.     (Donati.) 

In  the  second  stage  changes  take  place  in  the  form  of  the 
breasts,  being  due  undoubtedly  to  the  great  increase  in  weight. 
They  may  become  displaced  from  the  pectoral  muscles  and 


86  Diseases  of  the  Breast. 

fascia,  to  which  they  are  only  loosely  attached.  Alterations  in 
the  skin  also  occur.  The  veins  become  distended  and  thicken- 
ing and  edema  are  sometimes  observed.  Excoriations  and  ulcer- 
ations have  also  been  known  to  develop,  particularly  where  the 
skin  is  arranged  in  folds.  In  one  advanced  case  mentioned  by 
Marjolin  there  was  a  protrusion  of  glandular  tissue  through 
an  ulceration.  This  case  is  unique.  Whenever  inflammation 
supervenes  the  axillary  lymph-glands  may  become  involved. 

As  the  breasts  increase  in  size  they  become  exceedingly 
burdensome  and  may  greatly  interfere  with  respiration,  espe- 
cially when  the  patient  is  in  the  recumbent  position.  Pain  in 
the  ribs,  palpitation  of  the  heart,  and  distortion  of  the  spinal 
column  have  also  been  observed.  If  the  breasts  encroach 
markedly  upon  the  abdomen,  digestive  disturbances  and  con- 
stipation may  be  produced.  A  certain  degree  of  cachexia 
supervenes  in  cases  of  long  duration. 

The  size  attained  by  the  breasts  varies  greatly.  Thus  in 
some  cases  they  weighed  not  more  than  four  or  five  pounds 
each,  whereas  in  others  their  combined  weight  was  found  to 
be  from  twenty  to  sixty  pounds. 

With  the  exception  of  those  cases  occurring  in  pregnancy 
the  course  of  the  disease  is  progressive.  It  may  continue  for 
many  years.  In  an  exceptional  case  reported  by  Donati, 
however,  the  condition  remained  stationary  after  about  two 
months'  progression. 

The  cases  associated  with  pregnancy  are  favorable,  the 
breasts  often  returning  to  their  normal  size  after  the  pregnancy 
is  terminated.  The  course  of  gestation  is  not  interfered  with. 
Cases  have  been  reported  in  which  the  disease  developed  a  sec- 
ond time  with  the  recurrence  of  pregnancy. 

In  regard  to  treatment  it  may  be  stated  that  amputation  of 
the  breast  is  indicated  in  all  cases  other  than  those  associated 
with  pregnancy,  provided  that  the  hypertrophy  is  sufficient  to 
produce  disturbances  of  any  consequence.     The  progressive 


Diffuse  Hypertrophy.  87 

nature  of  the  disease  tends  to  make  its  treatment  surgical. 
Beginning  cases  and  those  of  slight  degree  have  been  treated  by 
means  of  compression  and  the  application  of  iodine  ointment, 
but  to  me  it  seems  irrational  to  expect  much  from  such  measures. 
As  already  stated  the  disease  is  essentially  a  diffuse  fibroma. 
Therefore  it  is  hardly  probable  that  the  above-mentioned  meas- 
ures will  exert  much  influence  upon  it. 

Amputation  of  the  breasts,  however,  has  always  resulted  in 
cure.  Owing  to  the  increased  vascularity  of  the  parts,  trouble- 
some hemorrhage  has  been  encountered,  and  for  this  reason 
it  has  been  advised  to  transfix  the  organs  at  their  base  with  long 
pins  and  then  make  compression  by  means  of  an  elastic  band 
passed  around  them.  Amputation  of  the  second  breast  has  also 
been  deferred  until  complete  recovery  took  place  from  the  first 
operation. 

Expectant  treatment  is  indicated  in  the  cases  associated  with 
pregnancy,  for  as  already  stated,  the  process  undergoes  resolu- 
tion after  the  period  of  gestation  is  passed. 


KELOID. 

This  disease,  which  is  in  reality  an  overgrowth  of  fibrous 
tissue  beginning  around  the  blood-vessels  of  the  corium, 
is  of  importance  when  it  affects  the  skin  of  the  breast,  as  is 
not  uncommonly  the  case,  for  the  reason  that  it  may  be  mis- 
taken for  incipient  or  recurrent  carcinoma.  In  the  mind 
of  a  patient  the  so-called  spontaneous  keloid,  first  clearly  denned 
by  Alibert,  often  causes  fear  that  she  is  the  subject  of  malignant 
disease,  and  the  secondary  or  cicatricial  form,  particularly  if 
it  develop  on  scars  following  incisions  for  malignant  tumors, 
may  give  rise  to  apprehension  that  the  disease  is  breaking  out 
again,  and  thus  worry  both  patient  and  physician  until  its  true 
nature  is  determined. 

In  regard  to  the  etiology  of  keloid  little  is  known.  Formerly 
it  was  thought  to  develop  solely  in  scars,  but  Alibert,  as  already 
stated,  called  attention  to  what  he  termed  a  primary  or  idio- 
pathic form  of  the  disease,  which  he  thought  developed  irre- 
spective of  injury.  Further  investigations,  however,  have  led 
to  the  conclusion,  at  least  by  most  observers,  that  there  is  in- 
variably an  antecedent  injury,  be  it  ever  so  slight,  which  sup- 
plies a  basis  for  the  development  of  the  disease.  Cases  have 
been  known  to  occur  in  which  no  history  of  the  slightest  trau- 
matism could  be  obtained,  but  if  it  be  granted  that  a  scratch 
or  excoriation  be  sufficient,  in  those  whose  tissues  are  predis- 
posed, to  set  up  a  morbid  increase  of  cells,  the  futility  of  relying 
on  absence  of  a  history  of  injury  becomes  at  once  apparent.  I 
do  not  believe  in  the  existence  of  idiopathic  keloid. 

The  disease  has  been  observed  superimposed  upon  the  scars 
following  burns  of  the  mammary  integument,  furuncles,  and 
those  following  the  simple  incision  of  abscesses,  as  well  as  those 


Keloid.  89 

following  more  extensive  injuries  and  operative  procedures. 
Negroes  are  specially  predisposed. 

Symptoms. — Keloid  may  be  either  single  or  multiple.  It 
occurs  as  round,  oval,  or  oblong  nodules  or  plaques,  of  a  white, 
pink,  red,  or  purple  color.  Very  frequently  prolongations  of  the 
new  fibrous  tissue  stretch  outwards  from  the  body  of  the  growth, 
giving  it  a  claw-like  appearance.  These  growths  increase  in 
size  very  slowly  and  seldom  produce  any  subjective  symptoms. 
Occasionally,  however,  itching  or  pain  is  present. 

There  should  really  be  no  difficulty  in  diagnosticating  keloid, 
although  if  the  disease  develops  upon  scars  made  in  removing 
the  breast  for  malignant  disease,  it  may  at  first  be  mistaken 
for  a  recurrence.  The  peculiar  character  of  the  lesions,  how- 
ever, should  at  once  furnish  an  inkling  as  to  their  nature,  which 
will  be  positively  revealed  as  they  progress.  The  so-called 
spontaneous  keloid  should  offer  no  difficulty  of  diagnosis.  The 
slow  growth  and  the  not  uncommon  claw-like  projection,  as 
well  as  the  other  characteristics  above  mentioned,  should  serve 
to  distinguish  it  from  scirrhus,  provided,  of  course,  that  the 
existence  of  such  a  disease  as  keloid  be  borne  in  mind. 

As  to  prognosis  it  may  be  said  that  the  disease  is  very  rebel- 
lious to  treatment,  and  that  it  persists  for  a  long  time.  Spon- 
taneous diminution  in  size  and  even  complete  disappearance 
have  been  known  to  take  place  in  cases  which  had  resisted  all 
therapeutic  efforts.  The  disease  is  benign  and  does  not  endan- 
ger life;  moreover,  it  seldom  causes  the  patient  any  suffering. 

Treatment  is  not  very  satisfactory.  Operation  as  practised 
in  the  past  has  been  almost  always  followed  by  recurrence. 
If  done  at  all  the  lines  of  incision  should  be  carried  far  beyond 
the  diseased  area,  so  that  an  extensive  removal  of  tissue  may  be 
effected.  The  wound  should  be  skin-grafted  instead  of  being 
sutured,  as  it  has  been  demonstrated  that  recurrence  often  takes 
place  at  the  site  of  the  needle  puncture.  I  am  satisfied  that 
the  cases  I  have  grafted  did  much  better  than  those  where 


90  Diseases  of  the   Breast. 

suturing  was  practised,  and  the  explanation  would  seem  to  lie 
in  the  avoidance  of  tension  and  sutures. 

I  was  led  to  make  this  suggestion  many  years  ago,  and  an 
increased  experience  has  only  tended  to  confirm  the  opinion 
then  expressed  to  the  Louisville  Surgical  Society. 

Having  seen  excellent  results  follow  the  use  of  the  X-rays, 
which  undoubtedly  cause  some  absorption  of  the  growth  and 
a  more  supple  condition  of  the  cicatrix,  I  am  inclined  to  try 
this  treatment  in  all  cases  before  resorting  to  operation.  Elec- 
trolysis has  also  seemed  to  cause  a  diminution  in  the  size  of  the 
lesions  in  a  few  cases,  but  it  more  often  has  failed. 


TUMORS. 

Before  taking  up  the  specific  tumors  of  the  breast,  it  may  not 
be  amiss  to  devote  a  little  attention  to  tumors  in  general  and  the 
relation  they  bear  to  those  in  which  we  are  most  interested. 
The  nature,  origin  and  classification  of  tumors  have  long  con- 
stituted a  much  mooted  question.  Authors  differ  in  their  con- 
ceptions as  to  the  nature  and  origin  of  the  individual  tumors, 
so  that  many  definitions  have  been  given. 

The  two  predominating  views  held  by  oncologists  as  to  the 
nature  and  origin  of  tumors  in  general  are  those  of  Virchow 
and  Cohnheim.  Virchow  taught  that  tumors  developed  by 
metaplasia  of  adult  tissue  under  proper  stimulus  or  in  the 
absence  of  proper  restraint,  placing  practically  no  limitations 
upon  its  possibilities,  claiming  that  connective  tissue  can 
be  transformed  into  epithelium  and  vice  versa.  Cohnheim 
took  diametrically  the  opposite  view,  referring  every  tumor- 
formation  to  the  embryonal  state,  describing  a  tumor  as  a 
"circumscribed,  atypical  production  of  tissue  from  a  matrix  of 
superabundant  or  erratic  deposit  of  embryonal  elements." 
He  denies  the  possibility  of  metaplasia  and  refers  every  growth 
to  the  primary  embryonic  layers,  portions  of  which,  having 
been  arrested  at  some  stage  of  their  development,  have,  under 
stimulus,  taken  on  new  growth  and  developed  into  tumors. 
Senn,  in  his  work  upon  tumors,  does  not  accept  the  Cohnheim 
view  in  its  entirety,  but  claims,  with  Ribbert,  that  neoplasms 
may  also  be  due  to  remnants  or  "anlage"  of  post-natal  origin, 
giving  as  his  definition  of  a  tumor  a  "localized  increase  of 
tissue,  the  product  of  tissue  proliferation  of  embryonic  cells 
of  congenital  or  post-natal  origin,  produced  independently 
of   microbic   causes." 

91 


92  Diseases  of  the   Breast. 

None  of  these  views  has  been  universally  accepted,  and  it 
appears  that  they  may  all  be  used  to  explain  the  formation  of 
different  tumors  and  that  none  is  the  exclusive  explanation 
of  them  all.  The  inclusion  theory  is  undoubtedly  the  best 
explanation  that  has  thus  far  been  offered  of  the  formation 
of  the  dermoid  cysts  and  teratoid  growths,  which  are  almost 
invariably  found  in  the  center  line  and  contain  elements  of 
misplaced  epithelium  in  situations  in  which  metaplasia  cannot 
be  considered.  Again,  it  offers  an  excellent  explanation  for 
the  neoplasms  of  the  kidney  composed  of  adrenal  tissue  (hyper- 
nephromata.)  It  might  even  be  considered  in  many  of  the 
other  tumors,  as  sarcoma,  myxoma,  angioma,  enchondroma 
(in  areas  where  cartilage  is  not  a  normal  element),  but  that  it 
cannot  be  offered  in  explanation  of  all  the  tumors  appears 
evident  from  the  examples  that  can  so  frequently  be  seen  of 
direct  metaplasia  of  normal  structures  into  malignant  growths. 
It  is  a  well-recognized  fact  that  carcinoma  of  the  lip  usually 
affects  pipe  smokers;  that  carcinoma  of  the  tongue  is  fre- 
quently caused  by  a  jagged  tooth;  that  carcinoma  of  the 
uterus  is  most  common  in  those  who  have  borne  children  and 
have  suffered  laceration  of  the  cervix;  that  carcinoma  of  the 
breast  has  a  frequent  antecedent  history  of  injury;  that  mel- 
anotic sarcomata  often  follow  injury  to  pigmented  moles;  that, 
in  certain  races,  keloids  often  follow  injury  to  any  part  of  the 
body;  that  carcinoma  of  the  stomach  is  most  frequently  found 
following  history  of  ulcer,  and  in  the  pyloric  region,  and 
that  carcinoma  of  the  gall  bladder  is  frequently  found  in 
conjunction  with  gall  stones.  The  above  examples  might  be 
multiplied,  but  they  will  suffice  to  illustrate  the  class  of  cases 
in  which  it  is  rather  difficult  to  attribute  the  formation  of  the 
growths  to  the  Cohnheim  theory.  It  appears  unlikely  that 
these  "anlage"  should  be  deposited  only  in  regions  which  are 
most  subjected  to  injury.  Finally,  in  some  carcinomata  of 
the  breast,  direct  transition  of  normal  acini  into  malignant 


Tumors.  93 

growths  can  be  detected;  likewise  in  certain  fibromata,  the 
direct  metaplasia  into  malignant  sarcomata  can  be  seen  by 
the  microscope  as  well  as  corroborated  by  the  clinical  history. 

From  the  above,  it  appears  most  rational  to  attribute  the 
origin  of  tumors  to  both  sources,  some  as  explained  by  the 
Cohnheim  or  even  the  Senn  theory,  and  some  to  direct  meta- 
plasia, as  maintained  by  Virchow.  Metaplasia  undoubtedly 
does  occur  but  not  to  the  extent  claimed  by  Virchow.  One 
tissue  may  be  transformed  into  a  related  tissue  of  similar  epi- 
blastic,  mesoblastic,  or  hypoblastic  origin,  but  that  a  meso- 
blastic  tissue  becomes  converted  into  a  hypoblastic  or  epiblastic 
tissue,  and  vice  versa,  appears  to  me  to  be  untenable.  They 
are  essentially  different  at  birth  and  remain  so  until  death. 
The  apparent  cases  of  mouse  carcinoma  becoming  converted 
into  sarcoma  by  transplantation  are  evidently  due  to  the  malig- 
nant metaplasia  of  the  stroma  of  the  growth,  which  has  prolif- 
erated to  such  an  extent  as  finally  to  overshadow  the  original 
epithelial  growth  and  to  appear  as  sarcoma.  It  is  not  an  in- 
stance of  direct  metaplasia  of  epithelial  tissue  into  sarcoma, 
but  a  case  of  the  survival  of  the  most  active  element. 

In  accordance  with  the  above  views,  we  may  define  a  tumor 
as  a  newgrowth  characterized  by  a  histological  diversity  either 
of  nature,  amount,  or  arrangement  of  the  cells,  from  the  matrix 
in  which  it  grows,  having  no  beneficent  functional  activity 
and  not  microbic  in  origin. 

Tumors  can  be  classified  in  various  ways,  either  according 
to  the  conception  of  the  tumors  themselves  or  with  reference 
to  their  clinical  activities. 

From  the  pathological  point  of  view  tumors  may  be  divided 
according  to  Ribbert  as  follows: — 


94  Diseases  of  the   Breast. 

i.  Tumors  of  the  Supporting  Tissues  (Connective  Tissues), 
a.  Fibroma. 


b. 

Lipoma. 

c. 

Chondroma. 

d. 

Osteoma. 

e. 

Chordoma. 

f. 

Angioma.  . 

«,  sarcoma. 
P,  osteosarcoma. 
7,  chondrosarcoma. 
*,  lymphosarcoma. 

g.  Sarcoma. 

f,  myxoma. 
f,  chloroma. 
v,  myeloma. 
9,  melanoma. 

2.  Tumors  of  Muscular  Tissue. 

Myoma. 

3.  Tumors  of  Nervous  Tissue. 

Neuroma. 
Glioma. 

4.  Tumors  of  Combined  Epithelial  and  Connective 
Tissues. 

A.  Fibro-epithelial  tumors. 

a.  Cutaneous. 

b.  Originating  in  mucous  membranes. 

c.  Originating  in  glandular  structures. 

B.  Carcinomatous  tumors. 

5.  Chorionepithelioma. 

6.  Endothelioma. 

7.  Mixed  Tumors,  Embryoma,  Teratoma,  etc. 

This  classification,  which  is  based  upon  the  histological 
appearances  of  the  tumors,  is  far  from  ideal,  but  is  probably 
the  best  for  practical  purposes,  and  especially  when  applied 


Tumors.  95 

to  tumors  of  the  breast.  An  ideal  classification  would  be  based 
upon  the  embryological  basis  alone,  but  this  is  difficult  owing 
to  the  fact  that  whereas  many  of  the  tumors,  especially  of  the 
fibro-epithelial  variety,  etc.,  are  composed  principally  of  epi- 
or  hypo-blastic  tissues,  they  contain  a  connective  tissue  stroma 
of  mesoblastic  origin.  In  addition  combinations  of  almost  all 
forms  of  tumors  occur,  some  of  which  are  of  similar  and  others 
of  different  origin. 

It  will  be  noticed  that  the  classification  does  not  include  the 
infectious  granulomata  or  cystic  formations  due  to  retention 
of  normal  secretions.  These  are  not  true  neoplasms  and 
should  not  be  classed  as  tumors. 

While  the  above  classification  is  most  satisfactory  from  a 
pathological  point  of  view,  the  division  of  the  subject  which 
is  of  most  use  to  the  surgeon  is  that  which  deals  with  the  clinical 
behavior  of  the  tumors.  This  is  a  very  simple  one,  there 
being  but  two  distinct  classes,  viz.,  benign  and  malignant. 
Benign  tumors  may  be  briefly  defined  as  those  growths,  which 
per  se  exert  no  deleterious  action  upon  the  general  economy, 
whereas  malignant  tumors  may  be  defined  as  those  growths 
which  exhibit  no  signs  of  restraint,  but  progress  to  a  fatal 
termination.  Each  has  certain  characteristics  which  distinguish 
it,  and  which,  as  a  rule,  should  be  recognized  by  the  surgeon 
as  soon  as  encountered,  so  that  he  should  not  always  be 
compelled  to  depend  upon  the  pathologist  for  a  decision  as 
to  prognosis  and  treatment. 

Benign  tumors  are  usually  very  slow  in  growth  and  distinctly 
localized,  having  a  definite  capsule.  They  rarely  attain  ex- 
cessive size,  but  occasionally,  owing  to  their  intrinsically  benign 
character,  may  attain  huge  dimensions  without  injury  to  the 
general  economy.  Generally  they  are  movable  (unless  bound 
down  by  surrounding  inflammatory  tissue  or  primarily  attached 
to  bone).  They  do  not  metastasize  or  become  disseminated 
throughout  the  body,  and  when  completely  removed  do  not 


96  Diseases  of  the  Breast. 

recur.  They  exert  no  influence  whatever  upon  the  general 
economy  when  favorably  situated,  but  may  endanger  life  by 
their  size  and  situation  when  they  interfere  with  the  normal 
functions  of  any  of  the  important  organs  of  the  body.  They 
constitute  the  bulk  of  the  tumors  of  youth,  and  need  be  removed 
only  because  of  their  size  and  location  and  because  of  the 
ever  present  danger  of  transformation  into  their  correlated 
forms  of  malignant  disease. 

Microscopically  they  can  be  distinguished  by  their  non- 
infiltrating character,  by  their  distinct  encapsulation,  by  their 
tendency  to  conform  to  some  definite  type  of  normal  adult 
tissue,  and  the  absence  of  an  actively  growing  edge  with  an 
abundance  of  cells  showing  karyokinetic  figures. 

Malignant  tumors  exhibit  diametrically  opposite  character- 
istics. They  grow  rapidly  and  usually  diffusely.  They  are 
not  encapsulated  and  may  quickly  attain  considerable  size, 
although  huge  malignant  tumors  are  rather  exceptional,  since 
they  usually  prove  fatal  before  they  attain  such  proportions. 
They  are  intimately  connected  with  the  surrounding  tissues 
and  quickly  become  bound  down  and  immovable.  They 
metastasize  and  become  disseminated  rapidly  through  the 
lymph  or  vascular  system,  progressing  steadily  toward  a  fatal 
termination  by  the  interference  with  vital  functions  caused  by 
metastatic  growths,  or  by  an  auto-intoxication  which  under- 
mines the  general  health  and  produces  the  condition  commonly 
known  as  cachexia. 

Microscopically  they  can  be  distinguished  by  the  embry- 
onal character  of  the  cells  constituting  the  growth  and  by  their 
atypical  structure,  conforming  to  no  definite  adult  normal 
tissue.  They  can  be  seen  to  be  rapid  in  their  growth  by  the 
abundance  of  cells  undergoing  indirect  cell  division.  They 
are  not  encapsulated,  but  tend  to  invade  surrounding  struc- 
tures, blood  and  lymph  channels,  a  circumstance  which  ex- 
plains their  ready  metastasis. 


Tumors.  97 

Each  layer  of  the  original  ovum  is  represented  by  one  ma- 
lignant tumor.  The  epi-  and  hypoblast  are  represented  by 
the  carcinomata  and  the  mesoblast  by  the  sarcomata.  There 
are  several  types  of  each,  but  they  are  all  related  one  to  the 
other  and  all  show  some  conformity  to  the  above  character- 
istics.    All  the  other  tumors  are  benign  in  nature. 

Before  taking  up  the  consideration  of  the  tumors  particu- 
larly common  in  the  breast,  a  few  words  remain  to  be  said 
with  reference  to  the  differences  which  distinguish  the  carci- 
nomata and  the  sarcomata.  First  and  foremost  is  the  char- 
acter of  the  cells  which  constitute  the  different  growths.  The 
sarcomata  are  composed  of  embryonal  connective  tissue 
cells,  being  either  round  (large  and  small),  spindle  (large 
and  small),  irregular  in  shape  or  polynuclear;  whereas  the 
carcinomata  are  usually  larger,  polygonal  or  columnar  in 
shape  and  represent  atypical  forms  of  squamous  or  acinous 
types  of  tissue.  The  sarcomata  grow  with  practically  no 
stroma,  the  blood  supply  being  from  very  thin-walled  blood- 
vessels, which  are  in  intimate  contact  with  the  tumor  cells, 
by  which  they  are  frequently  invaded.  Carcinomata,  on  the 
other  hand,  frequently  possess  an  abundant  stroma  between 
masses  of  cells,  with  a  finer  stroma  between  the  individual  cells, 
the  cellular  element  encroaching  upon  the  lymph  channels  of  the 
surrounding  tissue  and  the  stroma  of  the  tumor  itself.  Sar- 
coma advances  with  a  solid  growing  edge,  encroaching  on  the 
surrounding  tissue  as  a  whole,  whereas  carcinoma  sends  out 
finger-like  projections  through  the  lymph  spaces,  the  new- 
growths  increasing  in  size  until  they  cause  destruction  of  the 
tissue  they  have  invaded. 

Sarcomata  become  disseminated,  as  a  rule,  by  invading  the 
vascular  system,  with  the  resulting  transportation  of  emboli 
to  distant  organs,  whereas  carcinomata,  while  they  may  at 
times  invade  the  system  in  a  similar  manner,  usually  do  so 
by  way  of  the  lymphatic  system,  metastasis  occurring  first 
7 


98  Diseases  of  the  Breast. 

in  the  nearest  chain  of  lymphatic  glands  and  trunks,  from  them 
to  others  more  distant,  and  finally  throughout  the  economy. 
As  a  result  of  these  differences  in  methods  of  dissemination, 
sarcomata  will  recur  locally  after  operation  should  the  pri man- 
growth  not  be  thoroughly  removed,  but  otherwise  at  some  far 
distant  point;  while  carcinoma,  perhaps  when  thoroughly  re- 
moved at  the  site  of  the  local  growth,  shows  a  tendency  to 
recur,  not  locally,  but  in  the  nearest  lymphatic  structures, 
and  only  late  in  the  disease  shows  general  organic  involve- 
ment. 

Finally,  as  a  clinical  difference  of  some  value,  but  not  so 
great  as  has  been  claimed  in  times  gone  by,  is  the  difference 
in  the  age  of  the  patients  affected.  It  was  formerly  taught 
that  carcinoma  a  was  disease  of  old  age  (over  45)  generally; 
but  data  are  gradually  accumulating  which  tend  to  convince 
us  that  we  can  never  exclude  the  diagnosis  of  carcinoma 
merely  on  account  of  the  youth  of  the  patient,  the  writer 
having  observed  many  carcinomata  in  children,  and  carcino- 
mata  of  the  breast  have  been  noted  as  early  as  19  years.  The 
fact,  nevertheless,  remains  that  carcinoma  occurs  most  fre- 
quently after  forty  (40)  years  of  age. 

Sarcoma,  on  the  other  hand,  is  most  frequently  a  growth  of 
youth  or  middle  age  but  here  the  reverse  of  the  above  is  often 
found  to  be  true,  for  sarcomata  are  found  at  all  periods  from 
infancy  to  old  age. 

Concerning  the  benign  tumors,  little  need  be  added  to  that 
already  mentioned.  The  name  given  a  tumor  is  in  itsetf  a 
description  of  the  tissue  of  which  it  is  composed,  since  benign 
tumors  are  more  or  less  typical  of  normal  tissues  although  func- 
tionless  and  varying  from  the  normal  growth  only  in  their  situ- 
ations and  the  arrangement  and  comparative  amounts  of  the 
various  elements  of  which  they  are  composed.  In  the  tumors 
of  mesoblastic  structure,  when  composed  of  more  than  one  kind 
of  tissue,  the  name  is  usually  made  to  include  all  the  tissues 


Tumors. 


99 


comprised,  beginning  with  the  predominant  one  and  going  down- 
ward in  the  scale.  In  the  benign  hypo- 
and  epiblastic  tumors  the  same  rule  ap- 
plies, with  the  exception  that  themesoblastic 
element  is  not  regarded  unless  present  in 
excess  of  the  amount  required  as  a  con- 
necting stroma  for  the  epithelial  tissues. 
They  are,  however,  classified  under  the 
fibro-epithelial  tumors. 

All  that  has  been  written  above  applies 
to  tumors  wherever  situated,  but  it  does  not 
consider  the  relative  frequency  with  which 
certain  tumors  are  found  in  some  regions 
and  the  peculiarities  which  they  are  liable 
to  exhibit  in  various  situations.  Since  the 
portion  of  the  anatomy  with  which  we  are 
particularly  interested  is  the  breast,  we  can 
afford  to  devote  our  attention  to  it  at  once 
and  leave  the  other  organs  to  be  treated  in 
more  general  works. 

The  breast  is  not  prone  to  a  great  variety 
of  tumors,  although  it  is  one  of  the  most  fre- 
quent sites  in  the  body  for  some  of  them. 
While  the  whole  subject  of  the  etiology,  etc., 
will  be  treated  under  the  different  tumors, 
it  may  be  well  to  mention  here  that  carci- 
noma constitutes  more  than  three-fourths  of 
all  tumors  of  the  breast  and  that  the  great 
bulk  of  the  remainder  are  benign  tumors  of 
the  fibro-epithelial  type.  While  lipoma, 
angioma,    chondroma,    sarcoma,   myxoma      fig.  16.— showing  the 

J  relative  frequency  of  tu- 

and  endothelioma  do  occur,  they  constitute    mors  of  the  breast; 

i  ,  v    •it  ,',  -i  based  on  sooo  cases  col- 

an  almost  negligible  quantity  when  com-    lected  from  various  hos- 
pared  to  the  other  two  types  of  tumors.         pital  rePorts- 


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Diseases  of  the   Breast. 


The  benign  tumors  of  the  breast  have  been  so  well  "studied 
and  classified  by  Warren,  that  I  believe  the  best  scientific  ends 


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Fig.  17. — Showing  the  age  incidence  of  benign  tumors  of  the  breast; 
based  on  1000  cases  collected  from  various  sources. 


will  be  served  by  adhering  to  his  views  almost  in  toto,  at  the  same 
time  contributing  something  to  his  effort  at  harmonizing  and 
unifying  the  nomenclature  used  with  reference  to  tumors  of  the 


Tumors.  101 

breast  in  general.  He  has  struck  the  keynote  of  dissimilarity 
which  exists  between  these  benign  tumors  when  he  classifies 
them  all  together  as  fibro-epithelial  tumors  which  exhibit  some 
differences,  owing  to  the  disparity  in  the  nature  of  the  breast 
tissues  in  which  they  arise,  and  also  to  the  fact  that  their  growth 
is  intimately  associated  with  glandular  epithelium  which,  in 
some  instances,  forces  itself  into  prominence. 

These  growths  usually  occur  in  young  women,  their  greatest 
age  incidence,  as  shown  by  the  accompanying  chart,  being 
between  the  ages  of  twenty  and  thirty. 

Before  proceeding  with  the  individual  growths  I  will  give 
Warren's  classification,  filling  in  a  few  omissions  made  by  him, 
in  addition  to  giving  the  classification  of  the  carcinomata  which 
will  be  followed  in  this  book. 


BENIGN  TUMORS. 

Fibro-epithelial  tumors 

(i)     Fibrous  type: 

f  Intracanalicular. 


Periductal  fibroma 

(  Pericanalicular. 


2. 

Periductal  myxoma. 

3- 

Periductal  sarcoma  (slightly 

malignant) 

(2)  Epithelial  type: 

1. 

Fibro-cystadenoma. 

2. 

Papillary-cystadenoma. 

3- 

Simple  adenoma. 

Lipoma. 

Enchondroma. 

Myxoma. 

Angioma. 

Endothelioma. 

102 


Diseases  of  the   Breast. 


MALIGNANT  TUMORS. 


Sarcoma. 


I. 

Round  cell. 

2. 

Spindle  cell. 

3- 

Mixed  cell. 

4- 

Giant  cell. 

5- 

Alveolar. 

6. 

Melanotic. 

Carcinoma. 

i. 

Adeno-carcinoma. 

2. 

Medullary  carcinoma 

3- 

Carcinoma  simplex. 

4- 

Scirrhus  carcinoma. 

5- 

Carcinomatous  cyst. 

FIBRO-EPITHELIAL  TUMORS. 

By  the  term  fibro-epithelial  tumor,  which  was  first  used  by 
Ribbert,  is  understood  a  growth  of  new  formation  containing 
both  fibrous  connective  tissue  and  epithelium. 

Much  confusion  has  existed  in  regard  to  the  members  of  this 
group  of  tumors,  owing  to  the  diversity  with  which  their 
constituent  elements  may  appear,  and  likewise,  though  in  les- 
ser degree  perhaps,  to  the  difference  of  opinion  concerning 
their  origin.  It  is  principally  concerning  those  new  growths 
in  which  the  one  or  the  other  of  the  above  named  tissues  pre- 
dominated that  the  confusion  has  prevailed. 

Soon  after  the  existence  of  benign  tumors  of  the  breast  was 
recognized  by  Sir  Astley  Cooper  and  Cruveilhier  the  difficulty 
in  classifying  them  began.  There  can  be  no  doubt  that  the 
growth  described  by  Cooper  as  chronic  mammary  tumor 
belonged  to  the  class  now  under  discussion,  and  that  they  were 
identical  or  similar  to  the  ones  described  by  Cruveilhier  some 
years  later  as  fibroma.  Cruveilhier,  however,  maintained  that 
the  fibromata  were  quite  different  from  those  tumors  which 
Cooper  has  described.  He  believed  that  they  originated  in  the 
fibrous  connective  tissue  of  the  breast,  but  his  views  met  with 
much  opposition,  particularly  in  France,  after  the  existence  of 
benign  mammary  tumors  became  generally  recognized.  Addi- 
tional discord  was  lent  to  the  subject  by  Lebert,  who,  in  1850, 
made  the  first  report  of  the  microscopical  study  of  these  growths. 
I  am  quite  in  accord  with  Delbet,  however,  concerning  the  error 
which  Lebert  made,  being  convinced  that  his  mistake  consisted 
rather  in  the  selection  of  an  unfortunate  term  than  in  failure 
to  recognize  the  true  nature  of  the  growths.  Although  he 
called  these  tumors  partial  hypertrophy  of  the  breast,  he  stated 
clearly  that  in  some  the  hypertrophy  affected  chiefly  the  fibrous 

103 


io4  Diseases  of  the   Breast. 

tissue,  whereas  in  others  its  principal  site  was  in  the  glandular 
elements.  Despite  the  fact  that  he  was  attacked  from  all  sides 
and  his  idea  of  partial  hypertrophy  subjected  to  ridicule,  it  is 
plainly  manifest  that  the  result  of  his  observations  constituted 
a  decided  advance  in  the  knowledge  of  these  tumors.  Of 
course,  a  partial  hypertrophy  in  the  true  sense  of  the  word  is 
impossible,  but,  as  already  stated,  it  is  doubtful  if  Lebert  in- 
tended to  imply  the  existence  of  such  a  condition. 

The  presence  of  both  fibrous  and  epithelial  tissue  in  the 
tumors  was  likewise  recognized  by  Broca. 

Further  investigation  only  served  to  increase  the  multiplicity 
of  terms  and  lead  to  greater  diversity  of  opinion  in  regard  to  the 
origin  of  the  tumors.  It  was  observed  that  cyst-formation 
took  place  in  many  of  the  growths,  and  that  the  stroma  re- 
sembled sarcoma,  hence  the  term  cystosarcoma  was  applied 
to  this  form  by  Johannes  Miiller.  It  was  also  noticed  that 
the  epithelium  of  the  cysts  sometimes  proliferated,  and  so  the 
term  cystosarcoma  proliferum  was  used  to  distinguish  this  va- 
riety from  those  in  which  no  proliferation  occurred,  the  latter 
being  designated  as  cystosarcoma  simplex. 

With  few  exceptions  the  members  of  the  French  school  came 
to  accept  the  belief  that  these  tumors  were  of  glandular  origin, 
and  thus  the  name  adenoma  was  added  to  the  list.  To  those 
tumors  in  which  fissures  and  clefts  were  well-marked,  as  well 
as  to  those  in  which  true  cyst-formation  occurred,  the  term 
cystadenoma  was  given.  Papillary  cystadenoma  was  also 
spoken  of  to  designate  those  in  which  there  was  a  papillary  pro- 
liferation of  the  epithelium.  Sir  James  Paget  called  this  latter 
kind  proliferous  mammary  cysts,  and  designated  those  in 
which  cyst-formation  does  not  occur  as  mammary  glandu- 
lar tumors. 

Among  other  terms  which  have  been  used  at  various  times 
may  be  mentioned  adenocele,  cystoid  adenocele,  cystoid 
glandular  tumor,  and  cystic  fibroma. 


Fibro-epithelial  Tumors.  105 

Finally  after  the  presence  of  both  fibrous  connective  tissue 
and  epithelium  came  to  be  universally  recognized  as  essential  to 
all,  or  at  least  nearly  all  of  these  tumors,  and  the  instability 
of  the  mammary  glandular  epithelium  came  to  be  better  under- 
stood, matters  were  somewhat  simplified  by  the  adoption  of  the 
terms  adenofibroma  and  fibroadenoma,  according  as  one  or 
the  other  constituent  tissue  predominated  in  a  given  growth. 

Cystic  fibroadenoma  or  adenofibroma  was  applied  to  those 
in  which  cysts  formed,  and  when  marked  proliferation  of  the 
epithelium  took  place  papillary  cystadenoma  was  spoken  of. 

In  his  recent  admirable  paper  on  benign  tumors  of  the 
breast,*  Warren  called  attention  to  an  important  fact 
formerly  pointed  out  by  Billroth  and  also  recognized  by 
some  of  the  French  pathologists;  namely,  that  the  principal 
constituent  of  those  tumors  more  distinctly  fibrous  is  the  trans- 
parent periductal  tissue  of  the  mamma,  which  develops  during 
puberty  and  lactation.  Therefore  he  calls  this  type  of  tumor 
periductal  fibroma,  periductal  sarcoma,  and  periductal 
myxoma,  according  to  the  character  of  the  fibrous  tissue  pres- 
ent and  the  richness  of  cells.  These  forms  constitute  the 
fibrous  type  of  fibro-epithelial  tumors. 

The  epithelial  group,  those  in  which  the  glandular  element 
predominates  and  in  which  the  epithelium  is  subject  to  marked 
changes,  is  composed  of  two  members,  according  to  Warren's 
classification,  namely,  the  fibro-cystadenoma  and  the  papillary 
cystadenoma.  The  former  is  the  same  as  the  cystic  fibroma 
and  the  cystadenoma  proliferum.  The  latter  is  identical  with 
intracanalicular  cystadenoma  or  the  papillary  cystoma. 

In  addition  to  these  two  neoplasms  I  recognize  and  shall 
describe  the  simple  adenoma,  which  I  believe  to  be  a  definite 
pathological  entity,  though  very  rare. 

Etiology. — Various  influences  have  been  assumed  to  be  caus- 
ative of  the  fibro-epithelial  tumors,  but  if  the  effect  of  injury 

*The  Surgeon  and  the  Pathologist;  Jour.  Am.  Med.  Ass.,  July  15,  1905. 


io6 


Diseases  of  the   Breast. 


in  the  production  of  sarcoma  be  excluded,  it  remains  to  be 
proved  that  injury,  heredity,  pregnancy,  lactation,  or  inflam- 
matory disease  exert  any  causative  influence.  A  possible- 
exception  may  be  made  in  regard  to  the  papillary  cystadenoma, 
in  which  the  secondary*  proliferation  of  epithelium  seems  to 
depend  in  part,  at  least,  upon  the  functional  activity  of  the 
breast. 


in;.  iS. — Large  periductal  fibroma  of  right  breast. 

Periductal  Fibroma  (Fibroadenoma). 
These  tumors  occur  in  the  breast  as  firm,  round  or  ovoid, 
distinctly  encapsulated  bodies  of  varying  size  and  consistency, 
as  a  rule  being  single,  although  they  may  be  multiple.     They 


PLATE  VII. 


o 


Fibro-epithelial  Tumors.  109 

are  usually  found  in  one  breast  only,  but  occasionally  are  pres- 
ent in  both  at  the  same  time.  Of  slow  development,  they  may 
remain  of  inconsiderable  dimensions  for  a  long  period  of  time, 
or  they  may  increase  progressively  in  size  from  the  beginning 
of  their  appearance  in  the  mammary  tissues.  As  ordinarily 
met  with  they  are  about  as  large  as  an  English  walnut  or  a 
small  hen's  egg,  but  I  have  seen  them  no  larger  than  a  cherry 
and  then  again  as  big  as  an  orange.  A  few  cases  have  been 
recorded  in  which  these  tumors  attained  extraordinary  dimen- 
sions, some  having  been  removed  which  weighed  as  much  as 
six  or  seven  pounds.  In  this  era  of  modern  surgery,  however, 
such  tumors  are  not  likely  to  be  encountered,  for  the  reason  that 
they  will  usually  be  subjected  to  the  knife  at  a  much  earlier 
stage  of  their  evolution. 

In  regard  to  influences  producing  unwonted  rapid  growth 
in  these  tumors,  it  may  be  stated  that  some  have  been  observed 
to  increase  suddenly  in  size  during  the  menstrual  periods,  and 
that  pregnancy  in  many  instances  exerts  an  undoubted  stimu- 
lating effect  upon  their  growth.  It  has  been  observed  that 
tumors  which  had  remained  stationary  for  years  suddenly 
began  to  grow  after  the  occurrence  of  conception.  This  cir- 
cumstance in  their  natural  history  is  of  importance  in  reference 
to  prognosis  and  treatment,  and  lends  additional  weight  to  the 
judiciousness  of  removing  the  growths,  even  though  they  give 
rise  to  only  slight  or  perhaps  not  any  symptoms. 

Symptoms. — The  periductal  fibromata  are  freely  movable 
beneath  the  skin  and  are  not  attached  to  the  deeper  structures 
of  the  breast.  Indeed,  it  is  characteristic  of  them  that  they 
are  superficial.  As  concerns  their  location  the  majority  of  them 
are  found  in  the  upper  outer  quadrant  of  the  breast,  but  no  part 
of  the  gland  is  immune.  Neither  retraction  of  the  nipple  nor 
lymphatic  involvement  occurs.  As  these  tumors  increase  in 
size  they  become  lobulated,  and  may  thus  impart  an  irregular, 
uneven  feeling  to  the  palpating  finger  as  it  is  passed  over  their 


no  Diseases  of  the   Breast. 

surface.  Their  capsule  is  derived  from  the  fibrous  stroma  of  the 
breast.  Both  capsule  and  tumor  move  under  the  palpating  finger. 

Considerable  diversity  of  opinion  has  been  expressed  in 
regard  to  the  subjective  symptoms  produced  by  these  tumors, 
some  authors  stating  they  never  give  rise  to  pain,  and  others, 
as  Gross,  for  instance,  that  they  are  painful  in  the  majority  of 
cases.  Personally  I  have  rarely  known  them  to  give  rise  to 
severe  pain,  although'  I  have  frequently  had  patients  com- 
plain of  a  sense  of  uneasiness  in  the  breast  at  and  around 
the  site  of  the  tumor.  In  many  cases  this  symptom  was  espe- 
cially noticeable  during  the  catamenia.  Labbe  and  Coyne, 
and  after  them  Gross,  as  well  as  many  of  the  more  recent  French 
writers,  stated  that  small  tumors,  no  larger  than  a  pea,  fre- 
quently produce  severe  neuralgic  pain,  and  considered  them 
to  be  the  underlying  cause  of  many  obscure  cases  of  mastodynia. 
I  have  observed  such  a  phenomenon  in  only  a  single  case, 
and  therefore  consider  it  to  be  very  rare,  particularly  as  I 
have  seen  a  large  number  of  cases  during  the  last  twenty 
years.  The  case  in  question  was  that  of  a  married  woman, 
aged  thirty-eight  years,  who  complained  of  severe  pain  in  the 
left  breast,  which  she  had  experienced  in  greater  or  less  degree 
for  seventeen  years,  the  trouble  dating  from  an  inflammatory 
affection  requiring  incision.  Upon  examination  a  small,  hard 
tumor  about  the  size  of  a  cherry  was  found  in  the  lower  quad- 
rant of  the  breast.  This  growth  was  removed  and  after  the 
wound  healed  the  patient  declared  herself  to  be  free  from  pain. 
I  am  of  the  opinion  that  this  tumor,  which  proved  to  be  a  peri- 
ductal fibroma,  was  responsible  for  the  subjective  symptoms 
experienced.  It  evidently  was  of  very  slow  growth,  so  that 
it  was  not  detected  for  several  years. 

Morbid  Anatomy. — The  appearance  of  these  tumors  upon 
section  varies  somewhat  with  the  degree  of  their  development. 
When  still  young  the  cut  surface  is  white  or  rosaceous  in  color, 
whereas  when  older  they  are  gray  and  have  lost  something  of  the 


Fibro-epithelial  Tumors. 


i  i  i 


glistening  appearance  which  is  characteristic  of  the  younger 
growths.  The  line  of  demarcation  between  the  capsule  and 
the  substance  of  the  neoplasm  is  distinct.  Bundles  of  fibrous 
tissue  crossing  one  another  in  various  directions  can  be  plainly 
seen  in  the  older  growths.  Microscopically  they  show  both 
fibrous  stroma  and  glandular  elements   in  varying  amounts. 


mm 


Fig.  19. — Periductal  fibroma.     Microscopic  appearances.   {Warren.) 


In  one  form  the  fibrous  tissue  reaches  a  high  state  of  activity, 
the  epithelium  showing  little  tendency  to  proliferate.  As  a 
result  of  this  inequality  of  growth  distortion  occurs.  Tumors 
of  this  type  correspond  to  the  intracanalicular  fibroma. 

In  another  form  both  fibrous  tissue  and  epithelium  grow 
with  an  equal  degree  of  rapidity,  so  that  no  distortion  takes 
place.  In  a  cross  section  of  such  a  tumor  the  ducts  are  seen  to 
be  normally  preserved.  Tumors  of  this  type  correspond  to  the 
pericanalicular  fibroma. 


ii2  Diseases  of  the   Breast. 

Thus  some  are  dense  and  compact,  while  others  show  clefts 
and  dilatations.  If  the  dilatation  takes  place  rapidly  the  clefts 
are  irregular,  whereas  if  the  process  is  slow  they  are  at  first  some- 
what cylindrical  in  shape.  The  irregularity  is  due  to  compres- 
sion at  various  points  by  the  increasing  periductal  fibrous  tissue. 
Moreover,  this  growth  of  fibrous  tissue  enlarges  the  walls  of 
the  alveoli,  and  the  epithelium  which  lines  them  becomes 
arched  over  the  protuberances  or  invaginated  into  the  depres- 
sions which  are  formed  in  the  wall,  so  as  to  accommodate  itself 
to  the  enlarged  surface.     Such  enlargement  and  dilatation  may 


Fig.  20. — Large  periductal  fibroma  of  the  pericanalicular  type. 

amount  to  cyst- formation,  but  as  a  rule  the  spaces  are  not  large 
enough  to  be  termed  cysts. 

If  secondary  proliferation  of  the  epithelium  takes  place,  how- 
ever, it  results  in  cyst-formation,  and  we  then  have  to  do  with 
the  fibro-cystadenoma. 

FlBRO-CYSTADENOMA    (CYSTIC  ADENOMA,    POLYC YSTOMA) . 

Clinically  these  growths  differ  little  from  large  periductal 
fibromata,  being  firm  in  consistence,  lobulated,  and  rarely 
giving  rise  to  fluctuation.  They  are  freely  movable,  painless, 
and  do  not  cause  enlargement  of  the  axillary  lymphatic  glands. 


Fibro-epithelial  Tumors. 


"3 


They  commonly  affect  women  of  the  same  age  as  the  simple 
periductal  fibroma,  although  owing  to  the  slow  evolution  of 
the  latter  growths  the  cystic  changes  sometimes  do  not  occur 
until  the  tumor  has  existed  a  number  of  years.  Gross  observed 
that  cystic  changes  in  benign  tumors  of  the  breast  were  ordinar- 
ily found  in  those  tumors  removed  from  women  between  the 
age  of  thirty  and  forty,  rather  than  in  those  between  twenty 
and  thirty.     Although  a  portion  of  the  tumors  which  he  studied 


« 


•>  ft- 

.-     &  sfiK&    Vft*  m£&.S 


Fig.  21. — Fibro-cystadenoma.    Microscopic  appearances.   (Warren.) 

were  papillary  cystadenomata,  which  occur  later  in  life  than 
the  other  forms,  others  no  doubt  were  fibroadenomata  of 
slow  evolution  in  which  cystic  changes  had  taken  place  at  a 
late  period  of  their  existence. 

The  contents  of  the  cysts  varies  in  color  and  consistency, 
being  thin  and  clear  in  some  and  thick  and  opaque  in  others. 

Warren  observed  that  the  ducts  appeared  to  be  more  involved 
in  the  tumors  of  this  kind  which  he  studied  than  were  the  alveoli. 

8 


ii4  Diseases  of  the   Breast. 

The  important  thing  to  be  remembered  about  this  form  of 
tumor  is  that  it  is  really  the  same  as  the  periductal  fibroma 
except  that  a  secondary  proliferation  of  the  epithelial  elements 
has  taken  place. 

Papillary  Cystadenoma. 

In  this  form  of  tumor  still  greater  proliferation  of  epithelium 
occurs.  The  proliferation  takes  place  in  the  form  of  wart- 
like excrescences,  often  pear-shaped,  which  protrude  into  the 
cavity  of  the  cysts,  sometimes  almost  completely  filling  the  space 
within  them.  Not  infrequently  a  number  of  branches  are  given 
off  from  a  single  one  of  these  papillary  structures. 

A  multitude  of  names  has  been  applied  to  this  form  of  tumor, 
some  of  which  have  already  been  mentioned.  In  addition  to 
intracanalicular  cystadenoma  and  papillary  cystoma,  they 
have  been  called  villous  papilloma,  duct  papilloma  and  duct 
cancer. 

Warren  has  described  these  growths  so  accurately,  both 
structurally  and  clinically,  that  I  will  quote  from  his  article 
verbatim. 

"The  histologic  picture  of  a  papillary  or  warty  outgrowth 
is  that  of  a  connective  tissue  pedicle  surmounted  by  an  epithe- 
lial covering.  Papillary  structures  of  this  character  are  the 
distinguishing  feature  of  the  tumors  of  this  group  and  serve 
to  differentiate  them  absolutely  from  other  benign  tumors  of 
the  breast.  Tumors  of  this  character  rarely  attain  great  size. 
Their  consistency  is  hard,  although  fluctuation  may  occasion- 
ally be  detected.  Adherence  to  the  skin  and  enlargement  of 
the  axillary  glands  are  not  to  be  expected.  The  situation  of 
the  tumor  in  the  breast  is  generally  beneath  or  in  close  relation 
to  the  nipple.  The  fluid  contents  of  the  cyst  is  generally 
hemorrhagic.  Microscopic  section  shows  the  characteristic 
papillary  outgrowths  of  connective  tissue  surmounted  by  a 
luxuriant  growth  of  epithelium.    The  epithelium  in  these  cases 


PLATE  VIII 


_,jrf*i;- 


Papillary  Cystadenonia.    Showing  appearance  of  the  tumor  when 
removed  with  contiguous  tissues.— (Maurice  H.  Richardson.) 


PLATE  IX. 


o 


P4 


Fibro-Epithelial  Tumors. 


117 


presents  the  characteristics  of  ductal  rather  than  acinal  epithe- 
lial cells." 


Fig.  22. — Papillary  cystadenoma.  Microscopic  appearances.  Note  exuber- 
ant growth  of  epithelium  over  papillary  outgrowths  of  connective  tissue  from  the 
wall  of  the  cyst  cavity.     (Warren.) 

In  twenty  cases  studied  by  Greenough  and  Simmons  there 
was  a  history  of  trauma  in  five,  no  such  history  in  seven, 


n8  Diseases  of  the  Breast. 

and  no  data  could  be  obtained  relative  to  the  subject  in  the 
remaining  eight.  One  case  occurred  in  a  man  aged  fifty- 
one.  In  Warren's  cases  the  average  incidence  was  fifty-two 
years.  In  the  twenty  studied  by  Greenough  and  Simmons  it 
was  forty-nine  and  one-half  years.  Thus  it  is  seen  that  the  dis- 
ease is  most  common  in  middle  life.  The  youngest  patient  was 
nineteen,  the  oldest  eighty-one,  so  that  no  age  would  seem  to 
confer  immunity.  Of  nineteen  women  eleven  were  married 
and  eight  had  had  children.  Thus,  there  were  eleven  whose 
breasts  had  not  undergone  lactation,  a  circumstance  which 
would  tend  to  show  that  pregnancy  and  lactation  are  not  pre- 
disposing causes.  Warren,  however,  expressed  the  opinion 
that  women  who  have  borne  and  reared  a  number  of  children 
are  particularly  predisposed. 

These  tumors  are  of  slow  growth,  are  only  slightly  if  at  all 
painful,  and  are  usually  situated  just  beneath  the  nipple.  They 
are  usually  firm  in  consistency,  although  when  large  they  may 
yield  readily  to  the  palpating  finger,  imparting  a  sense  of  elast- 
icity to  it.  The  most  characteristic  symptom  is  said  to  be  the 
discharge  of  bloody  fluid  from  the  nipple.  This  discharge 
may  exist  for  a  long  time  before  a  tumor  is  discovered  in  the 
breast,  as  was  the  case  with  three  patients  mentioned  by  Green- 
ough and  Simmons. 

According  to  these  authors  the  condition  with  which  papil- 
lary cystadenoma  is  most  likely  to  be  confounded  are  cancer, 
abnormal  involution  and  periductal  tumors. 

From  cancer  they  are  to  be  differentiated  by  their  slow 
growth,  definite  outline,  and  by  the  freedom  of  skin,  muscles 
and  axillary  glands  from  involvement  in  the  disease. 

From  abnormal  involution  the  diagnosis  is  more  difficult. 
Serous  discharge  from  the  nipple  in  such  cases  is  occasionally 
noted.  The  diffuse  character  of  this  condition,  however,  and 
the  irregular  nodular  consistency  of  the  breasts,  associated 
with  pain  and  tenderness  are  points  that  aid  in  differentiation. 


PLATE  X. 


A 


Papillary  cystadenoma.     A.  External  appearance  of  the  tumor. 
B.   Interna]  appearance.     {Maurice  H.  Richardson.) 


Fibro-epithelial  Tumors.  121 

Involution  changes  are  also  more  common  in  the  periphery  of 
the  breast,  while  papillary  tumors  occur  almost  invariably  near 
the  nipple. 

From  periductal  fibromata,  the  diagnosis  should  not  be 
difficult.  The  periductal  tumors  occur,  as  a  rule,  at  a  much 
earlier  age.  They  are  firm  and  elastic,  often  of  large  size, 
and  rarely  occur  near  the  nipple.  They  slip  and  slide  in  the 
breast  tissue,  and  never  produce  discharge.  The  periductal 
fibromata  are  far  more  likely  to  be  confused  with  the  fibro- 
cystadenomata  (the  other  type  of  the  cystadenoma  or  epithelial 
group)  and  it  is  doubtful  if  the  two  can  be  distinguished  with- 
out the  aid  of  the  gross  and  microscopic  examination.  (Annals 
of  Surgery,  February,  1907.) 

Simple  Adenoma* 

Simple  adenoma  is  the  rarest  type  of  the  fibro-epithelial 
tumors  of  the  breast,  Gross  having  observed  only  one  in  115 
breast  tumors,  Billroth  only  one  in  103,  McFarland  only  one 
in  a  very  large  experience.  This  tumor  must  not  be  con- 
founded with  the  adenoma  usually  described  in  the  text-books 
and  monographs  dealing  with  neoplasms  of  the  breast,  for  they 
usually  refer  to  the  other  forms  of  fibro-epithelial  tumors. 

Simple  adenoma  is  usually  found  as  a  definitely  localized, 
soft,  nodular  growth  occurring  in  young  adult  to  middle  age. 
It  is  not  adherent  to  the  skin  but  is  intimately  associated  with 
the  gland  structure.  It  is  freely  movable  over  the  underlying 
muscles.  On  section  it  is  usually  white  or  flesh  colored,  soft, 
and  at  times  exudes  a  substance  that  resembles  milk.     It  may 

*  I  have  added  this  tumor  to  Warren's  classification  of  benign  growths. 
Since  this  article  was  written  I  have  discussed  the  subject  with  Prof.  Coplin, 
of  Jefferson  Medical  College,  who  examined  hundreds  of  sections  from  Gross's 
specimen.  Prof.  Coplin  states  that  no  other  tissue  but  that  of  pure  acinous 
type  could  be  found.  The  same  condition  obtains  relative  to  the  growth 
shown  in  Plate  XI.     Of  course  the  normal  stroma  of  the  gland  is  present. 


i22  Diseases  of  the  Breast. 

appear  as  one  solid  tumor  or  may  be  broken  up  into  smaller 
nodules  by  thick  septa  of  connective  tissue.  It  is  benign  in  its 
growth,  not  giving  metastasis  to  the  lymph  glands  or  internal 
structures. 

Microscopically  a  simple  adenoma  is  seen  to  be  composed  of 
numerous  gland  acini  placed  close  together,  separated  by  only 
a  very  delicate  stroma  of  connective  tissue.  (See  Plate  XL)  The 
acini  arc  usually  lined  with  a  single  layer  of  cubical  epithelium, 
but  some  may  show  proliferation  of  the  epithelium  until  it  en- 
croaches considerably  upon  the  lumen  of  the  acinus.  In  these 
instances  there  is  usually  degeneration  of  the  central  cells  with 
the  formation  of  a  material  resembling  milk.  Scattered  through- 
out the  groups  of  acini  are  usually  some  ducts,  which  are 
commonly  blind,  although  Gross  considers  the  expulsion  of 
milk  from  the  nipple  on  pressure  over  the  tumor  as  a  diagnos- 
tic point  of  considerable  value.  If  such  is  the  case,  some  of 
the  tubules  must  connect  with  the  normal  galactophorous  ducts. 
The  essential  and  differentiating  points  about  this  growth 
are  the  great  preponderance  of  the  glandular  acini  over  the 
very  small  amount  of  stroma  and  the  fact  that  the  epithelium 
lining  the  acini  is  strictly  confined  by  the  membrana  propria. 
It  exhibits  no  tendency  to  cyst-formation,  infiltration  or  atyp- 
ical epithelial  proliferation.  Should  any  portion  of  the  tumor 
become  infiltrating  in  character,  it  should  no  longer  be  con- 
sidered an  adenoma,  but  be  immediately  placed  among  the 
adeno-carcinomata. 

Prognosis. — In  regard  to  the  prognosis  of  the  fibro-epithelial 
tumors,  it  may  be  stated  that  all  are  benign  growths,  which  do 
not  recur  after  complete  removal.  The  cases  in  which  recur- 
rence has  been  supposed  to  take  place  are  those  in  which  rem- 
nants of  the  tumor  were  left  behind,  or  in  which  growths  so  small 
as  to  escape  notice  at  the  time  of  operation  later  developed  and 
thus  lead  to  the  belief  that  the  original  tumor  had  grown  again. 
The  papillary  cystadenoma  may  undergo  malignant  changes. 


PLATE  XI. 


r"<  •      a.  «,.;■?'«.  -.  .  *.''•'•  -^VI*  -ib'D'ywV'     •"  vino's.  ■V'js  i»  »; .       .t  :re>>;  ^    ,,«  :z>  /■>     Vi 
.y»  i  \:»Si**«y,?*"*i  ■7>i>Al»Z-  MV"    ■■  *****  **V  *-*e£&    vW;,i  -  A  >■•«?■  -  '°"" 


v^rar 


Simple  adenoma.     Microscopic  appearance.     (Drawing  made  from  a  specimen 
loaned  by  Dr.  George  P.  Mailer,  of  the  University  of  Pennsylvania.) 


Fibro-epithelial  Tumors.  125 

In  three  out  of  twenty  cases  recently  analyzed  by  Greenough 
and  Simmons,  associated  carcinoma  was  found,  cancerous 
nodules  being  present  in  the  cyst- wall.  It  is  stated  that  except 
for  the  infiltration  of  surrounding  tissues,  the  nodules  presented 
characteristics  of  growth  of  the  same  general  character  as  the 
papillary  structures  within  the  cyst.  The  irregular  cell  growth 
and  the  infiltration,  however,  left  no  doubt  about  the  diag- 
nosis   of    adenocarcinoma.     (Annals   of    Surgery,   February, 

1907O 
The  duration  of  these  cancer  cases  was  nine,  twelve  and 

eighteen  months  respectively,  and  their  ages  were  fifty-two, 

sixty-nine  and  seventy-six  years. 

The  axillary  glands  were  not  palpably  enlarged  in  any  of 
these  cases,  and  in  two  in  which  the  axilla  was  cleared  out 
no  evidences  of  disease  were  found. 

In  two  of  the  patients  no  evidences  of  recurrence  were  found 
at  the  expiration  of  one  and  two  years.  The  third  patient, 
however,  died  of  recurrence  four  years  after  the  operation. 
With  early  and  complete  removal,  however,  the  prognosis 
of  this  group  of  tumors  is  favorable. 

Treatment  of  the  fibro-epithelial  tumors  is  purely  surgical 
and  consists  in  extirpation  of  the  growth. 

It  is  irrational  to  employ  such  local  measures  as  the  applic- 
ation of  iodine  or  mercurial  ointment  with  the  expectation 
that  they  will  even  in  the  slightest  degree  produce  retrogres- 
sive changes  in  the  tumor.  Their  effect  is  nil.  Spontaneous 
retrogression  is  not  to  be  counted  upon.  I  do  not  recall  a 
single  instance  in  which  it  has  taken  place. 

Small  growths  superficially  situated  may  be  excised  un- 
der cocaine.  For  others  I  prefer  the  plastic  resection  of  the 
breast  as  elaborated  by  Warren.  It  not  only  obviates  the 
necessity  of  inflicting  an  unsightly  scar,  but,  moreover,  enables 
the  surgeon  to  inspect  the  entire  breast,  and  thus  detect  the 
presence  of  small  tumors  which  may  be  present  and  which 


126  Diseases  of  the   Breast. 

could  not  be  located  if  simple  excision  of  the  principal  growth 
were  practised. 

The  operation  of  plastic  resection,  first  suggested  by  T. 
Gailliard  Thomas  and  recently  elaborated  by  Warren,  is  per- 
formed as  follows:  The  preliminary  incision  is  begun  at  the 
lower  border  of  the  breast,  opposite  the  middle  of  the  outer 
arc  of  the  lower  inner  quadrant,  and  runs  along  the  lower  fold 
and  outer  margin  to  the  inner  border  of  the  axilla,  thus  sever- 
ing the  lymphatic  connections  of  the  breast  with  the  axillary 
plexus  of  lymph  glands.  The  incision  should  be  carried  down 
to  the  lower  border  of  the  pectoralis  major  muscle,  which  should 
be  freely  exposed.  The  dissection  is  then  carried  along  through 
the  loose  connective  tissue,  which  lies  between  the  pectoral 
fascia  and  the  posterior  layer  of  the  fascia  in  which  the  mammary 
gland  is  contained.  With  the  left  hand  the  operator  reflects  the 
breast  upward  and  inward,  so  that  the  posterior  surface  becomes 
exposed  in  its  entire  length.  The  gland  tissue  can  now  be  seen 
through  transparent  fascia  and  easily  inspected,  and  any  cysts 
present  readily  seen.  Usually  one  or  two  lie  in  the  same  quad- 
rant, which  can  be  removed  by  a  Y-shaped  incision,  without 
opening  the  cysts.  The  apex  of  the  V  lies  directly  under  the 
nipple  in  the  center  of  the  gland.  Radiating  from  this  point 
incisions  can  be  carried  into  the  gland  tissue  in  all  directions, 
exposing  and  bisecting  all  small  cysts  so  that  none  remain 
which  have  not  been  laid  open.  A  second  V-shaped  incision 
may  occasionally  be  necessary,  but  this  is  rarely  the  case.  The 
next  step  after  arresting  hemorrhage  is  to  close  the  V  incision 
with  two  rows  of  catgut  sutures,  one  along  the  anterior  border 
and  one  bringing  the  posterior  edges  into  contact.  The  gland 
is  then  dropped  back  on  the  pectoral  muscle,  and  it  will  be 
found  that  the  various  incised  portions  resume  their  natural 
position  and  fit  accurately  together.  The  gland  is  then  anchored 
to  the  pectoralis  major  muscle  at  the  outer  edge.  Another 
row  of  sutures  is  advisable  to  hold  together  the  deep  layers  of 


Fibro-epithelial  Tumors.  127 

the  superficial  fascia  before  the  outer  edges  of  the  wound  are 
closed  with  silk-worm  gut.  The  buried  sutures  remove  tension 
from  the  surface  sutures.  The  dressing  is  so  applied  as  to 
produce  lateral  compression  of  the  two  hemispheres  of  the 
breast. 

It  has  been  stated  that  this  operation  endangers  the  nutri- 
tion of  the  gland  by  interfering  with  its  blood  supply,  but 
this  statement  is  based  upon  an  erroneous  conception  of  the 
manner  in  which  the  blood-vessels  of  the  breast  are  arranged. 
By  referring  to  the  section  on  anatomy  it  will  be  seen  that  the 
anterior  surface  and  portion  of  the  gland  receive  the  principal 
arterial  and  venous  channels,  and  not  the  posterior,  which  is 
the  one  chiefly  involved  by  the  incisions.  I  have  done  this 
operation  twenty  times  and  find  it  satisfactory  in  every  respect. 
In  all  these  cases  the  wound  healed  by  primary  intention. 


PLATE  XII. 


..V^*"* 


, 


PLATE  XIII. 


TLATE  XIV. 


a  a 


5.2 


PLATE  XV. 


PLATE  XVI. 


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g^; 


PLATE  XVII. 


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PLATE  XVIII. 


Showing  the  appearance  of  the  breast  after  extensive  removal  of  tissue 
for  multiple  cysts  in  the  operation  of  plastic  resection.  Notice  the 
slight  degree  of  deformity. 


PLATK  XIX. 


Showing  appearance  of  the  breast  after  plastic  resection. 


PLATE  XX. 


Showing  absence  of  scar  and  deformity  after  removal  of  a  benign  growth  from 
the  left  breast  by  the  operation  of  plastic  resection. 


LIPOMA. 

Lipomata  of  the  mammary  gland  are  rare,  although  they  oc- 
casionally occur;  they  may  develop  in  the  gland  itself  or  grow 
either  in  the  subcutaneous  tissue  or  in  the  retromammary 
region.  When  we  come  to  consider  the  abundant  supply  of 
fat  in  the  breast  the  question  naturally  arises  why  lipomata 
are  not  more  common  in  and  about  this  organ,  and  it  seems  to 
me  to  be  peculiar  that  they  are  not  more  often  met  with. 

In  regard  to  their  etiology  little  or  nothing  is  known.  They 
develop  in  the  breast  without  any  apparent  cause.  A  certain 
causative  influence  has  been  attributed  to  injury  in  a  few  cases, 
but  it  is  doubtful  whether  the  relation  between  the  traumat- 
ism and  development  of  the  tumor  was  one  of  cause  and 
effect. 

These  tumors  may  be  either  single  or  multiple,  and  may 
vary  much  in  size.  Usually  when  the  patient  comes  to  opera- 
tion the  tumor  is  not  larger  than  an  orange,  although  in  litera- 
ture cases  are  recorded  in  which  growths  of  enormous  size 
have  been  removed.  In  one  of  Sir  Astley  Cooper's  cases  the 
tumor  weighed  over  fourteen  pounds.  It  has  been  observed 
that  pregnancy  stimulates  them  to  active  growth.  The  sub- 
cutaneous variety  is  probably  the  most  common,  although  a 
number  of  cases  of  the  retromammary  form  have  been  recorded. 
The  former  are  always  encapsulated  by  a  thin  fibrous  mem- 
brane which  sends  septa  down  into  the  substance  of  the  tumor. 
Their  development  is  slow.  In  a  case  reported  by  Delage  and 
Massabiau  the  tumor  attained  the  size  of  an  orange  in  seven 
years.  They  are  not  sensitive  to  pressure,  but  are  frequently 
painful,  and  if  of  large  size  may  cause  discoloration  of  the 
skin  owing  to  the  congestion  which  they  produce  by  pressure. 

147 


148  Diseases  of  the   Breast. 

There  is  no  involvement  of  the  axillary  glands  and  no  tendency 
to  encroachment  upon  the  surrounding  tissues.  The  tumor, 
as  already  stated,  is  encapsulated,  and  therefore  well-defined, 
unless  it  be  of  large  proprotions  so  that  it  practically  obliter- 
ates the  gland.  Multiple  tumors  of  small  or  moderate  dimen- 
sions give  the  breast  an  uneven,  bosselated  appearance. 

It  is  characteristic  of  subcutaneous  lipomata  that  they  roll 
readily  between  the  thumb  and  fingers,  and  that  they  are  not 
hard  to  the  touch.  Indeed  they  have  been  mistaken  for  cystic 
tumors  and  galactocele  with  caseous  contents.  Moreover, 
they  are,  when  arising  near  the  axilla,  frequently  symmetrical, 
tumors  of  equal  size  and  shape,  being  found  on  either  side. 
They  also  are  frequently  pedunculated. 

Retromammary  lipomata  develop  between  the  gland  and 
the  great  pectoral  muscle,  and  as  they  increase  in  size  displace 
the  breast,  pushing  it  forward  or  to  one  side,  according  to 
their  site  and  the  direction  in  which  they  grow.  They  may 
attain  a  large  size  and  cause  congestion  and  discoloration  of 
the  skin  over  the  breast  exactly  as  do  large  subcutaneous  tumors. 

Intraglandular  lipoma  is  very  rare,  and  only  a  few  observa- 
tions have  been  recorded.  In  this  form  of  the  tumor  micro- 
scopic examination  reveals  the  presence  of  galactophorous  ducts 
traversing  the  substance  of  the  growth.  In  a  case  operated 
on  by  Demons  some  of  the  ducts  within  the  tumor  were  con- 
siderably dilated  and  filled  with  a  thick  yellow  substance  re- 
sembling coagulated  milk.  Others  were  somewhat  atrophied, 
their  lumen  appearing  like  a  transparent  point  in  the  surround- 
ing tissue.  In  some  the  epithelium  was  preserved  in  its  normal 
condition,  but  in  others  it  was  found  to  have  undergone  altera- 
tions. 

In  a  case  recently  reported  by  Delage  and  Massabiau  evi- 
dences of  myxomatous  degeneration  were  observed  in  the 
tumor. 

An  interesting  case  of  a  lipoma  containing  cartilage  has 


Lipoma.  149 

been  reported  by  Sick,  of  Hamburg.  The  tumor  was  removed 
from  the .  breast  of  a  woman  aged  seventy-two  years.  It 
was  made  up  of  firm,  pure  lipomatous  tissue,  throughout  which 
were  interspersed  small  areas  of  hyaline  cartilage  surrounded 
by  a  zone  of  fibrous  tissue. 

Lipomata  are  essentially  benign  tumors,  yet  their  removal 
is  always  indicated.  Single  or  small  multiple  subcutaneous 
growths  may  be  excised.  For  the  removal  of  retromammary 
and  intraglandular  growths  I  advise  plastic  resection  of  the 
breast,  unless  the  tumor  or  tumors  are  so  extensive  as  to  com- 
pletely destroy  the  gland,  in  which  case  amputation  is  the 
proper  measure  to  employ. 


ENCHONDROMA. 

Although  tumors  containing  cartilage  or  composed  entirely 
thereof  are  not  uncommon  in  the  breasts  of  certain  animals, 
particularly  bitches  and  she-goats,  they  are  rarely  found  in  the 
human  breast,  and  when  they  do  occur  it  is  usually  in  com- 
bination with  other  tissues  rather  than  as  pure  cartilaginous 
growths.  Thus  chondrosarcoma,  chondromyxoma  and  even 
chondrocarcinoma  are  more  frequently  met  with  than  pure 
enchondroma  or  chondro-osteoma. 

Instances  of  invasion  of  the  breast  by  cartilaginous  tumors 
originating  from  the  costal  cartilages  have  been  recorded, 
but  such  mammary  involvement  is  merely  a  secondary  change, 
and  is  not  to  be  considered  with  the  intrinsic  neoplasms  of  the 
gland. 

While  some  cases  which  have  been  recorded  as  enchondroma 
of  the  breast  were  undoubtedly  mixed  cartilaginous  tumors, 
that  is,  sarcomatous  or  myxomatous  growths  containing  car- 
tilage, pure  chondromatous  and  osteo-chondromatous  growths 
certainly  may  occur.  Thus,  for  example,  Sir  Astley  Cooper 
removed  a  tumor  which  was  undoubtedly  a  pure  enchondroma, 
and  Burck  removed  a  breast  containing  an  osteo-chondroma 
as  large  as  a  man's  fist. 

This  tumor,  which  was  carefully  examined  by  Edmund 
Leser,  who  reported  the  case,  was  taken  from  a  woman  aged 
sixty-seven  years.  It  was  first  noticed  sixteen  years  prior  to 
the  time  of  its  removal,  being  no  larger  than  a  hazel-nut.  There 
was  no  known  cause  for  its  development.  It  was  oval  in  shape, 
encapsulated,  firm,  and  resistant  to  the  knife.  The  cut  sur- 
face was  gray  in  color.  In  the  interior  of  the  growth  there  was 
a  bone-like  nodule  so  hard  that  it  could  not  be  cut  except  with  a. 
saw. 

150 


Enchondroma.  151 

In  another  case,  that  of  a  patient  operated  upon  by  Mazzu- 
chelli,  the  tumor  had  existed  even  longer  than  in  the  above 
case,  having  been  present  twenty-five  years.  During  this 
time  it  had  attained  the  size  of  an  egg,  and  gave  rise  to  pain 
only  six  months  before  it  was  removed.  This  tumor  was  also 
hard,  firm,  and  gray  in  color.  The  cut  surface  was  shiny,  and 
in  the  center  there  was  a  softened  area. 

Microscopic  examination  of  both  these  tumors  showed  them 
to  be  composed  of  cartilage  cells. 

These  two  cases  well  illustrate  the  slow  growth  of  enchon- 
dromatous  mammary  tumors,  and  the  absence  of  symptoms 
arising  from  their  presence. 

In  regard  to  the  etiology  of  these  tumors,  it  is  probable  that 
they  are  of  heterotopic  origin,  although  the  theory  that  the 
cartilage  develops  from  the  fibrous  tissue  of  the  breast  has  been 
advanced  by  different  investigators.  It  has  been  suggested 
again  only  recently  by  Cornil  and  Petit,  who  base  their  belief 
upon  the  circumstance  that  they  found  the  connective  tissue  to 
have  various  modalities,  such  as  the  myxomatous,  chronic 
inflammatory  and  pseudo-sarcomatous ;  and  also  upon  the 
fact  that  they  found  remains  of  mammary  tissue  in  ossified 
portions  of  the  tumors  which  they  examined.  I  must  confess, 
however,  that  I  find  it  difficult  to  relinquish  the  idea  that  tissue 
is  generated  from  tissue  of  its  own  kind,  and  therefore  hold 
to  the  inclusion  theory. 

It  seems  convenient  to  consider  in  this  place  the  mixed 
tumors  containing  cartilage. 

As  already  stated,  such  tumors  are  met  with  more  frequently 
than  pure  enchondromata.  The  cartilage  varies  in  quan- 
tity, in  one  being  contained  only  in  small  amounts,  whereas 
in  others  it  constitutes  the  greater  portion  of  the  tumor. 

In  chondrosarcoma  the  cartilage  may  form  well-defined 
trabecular. 

These  mixed  tumors  vary  in  size,  some  being  small  and 


[5.2  Diseases  of  the   Breast. 

others  large.  In  Dubar's  case  of  chondromyxoma  the  breast 
was  as  large  as  a  child's  head,  and  the  skin  had  ulcerated. 

A  very  interesting  case  of  mixed  cartilaginous  tumor  has 
been  recently  reported  by  Salomoni.  The  tumor  was  oval  in 
shape,  as  large  as  a  baby's  head,  and  was  well-defined  from 
the  skin,  the  great  pectoral  muscle,  and  the  surrounding  mam- 
mary tissue. 

A  small  cyst  containing  dark  viscous  fluid  was  present  in 
the  substance  of  the  growth. 

Upon  microscopic  examination  the  tumor  was  found  to  be 
made  up  of  a  stroma  of  fibrous  connective  tissue  arranged  in 
parallel  bundles,  containing  oval  and  round  cells  in  the  meshes 
of  the  stroma  and  in  the  cavities.  In  the  older  portions  of  the 
tumor  myxomatous  degeneration  was  detected,  and  zones  of 
fibro-cartilage  were  interspersed  throughout  the  section.  I 
incline  to  the  belief  that  all  such  mixed  tumors  are  prone  to 
become  malignant,  if  indeed  they  do  not  actually  represent 
malignant  growths  from  their  very  beginning.  For  this  reason 
I  advise  amputation  of  the  breast  as  the  proper  method  of 
treatment.  So,  too,  whenever  simple  cartilaginous  tumors  are 
diagnosticated  or  suspected  I  would  advise  removal  of  the 
breast.  As  already  stated,  I  believe  them  to  be  of  heterotopic 
origin  and  consider  them  likely  to  assume  malignant  propen- 
sities. Enchondromata,  wherever  situated,  are  dangerous  neo- 
plasms and  they  are  even  more  prone  in  the  breast  than  else- 
where to  undergo  malignant  transformation. 


MYXOMA. 

This  is  a  very  rare  growth  and,  indeed,  its  existence  as  a 
primary  neoplasm  has  been  questioned,  it  having  been  as- 
serted that  the  myxomatous  tissue  was  due  to  degenerative 
changes  in  other  growths. 

A  few  cases  have  been  reported,  however,  which  seem  to 
show  that  myxoma  may  exist  in  the  breast  as  a  primary  growth. 

A  good  example  of  such  a  case  has  been  recently  reported 
by  Clement.  It  was  that  of  a  woman,  aged  fifty-nine,  who  pre- 
sented a  voluminous  pedunculated  tumor  of  the  left  breast, 
which  extended  downwards  to  the  abdomen,  and  which  had  an 
extensive  area  of  suppuration  upon  its  lower  extremity.  The 
skin  over  the  remaining  portion  of  the  breast  was  much  dis- 
colored and  the  nipple  had  almost  disappeared.  Upon  palpa- 
tion the  tumor  was  found  to  be  soft,  fluctuating  and  uneven. 
There  was  no  axillary  involvement,  although  the  tumor  was 
of  three  years'  duration.  It  had  been  painful,  however,  from 
the  beginning. 

A  diagnosis  of  ulcerating  cystic  sarcoma  was  made  and 
the  breast  removed. 

The  tumor  was  found  to  be  encapsulated,  was  gelatinous 
upon  section,  and  showed  vascular  striations. 

Upon  microscopic  examination  it  was  found  to  be  composed 
essentially  of  mucous  tissue.  There  were  also  fibromatous 
and  hemorrhagic  areas.  The  normal  elements  of  the  gland 
had  nearly  all  disappeared. 

This  case  was  evidently  one  of  pure  myxoma,  as  the  tumor 
was  of  too  brief  existence  for  such  extensive  myxomatous  de- 
generation of  a  fibroma  to  have  taken  place. 

Such  instances  as  this  are  to  be  considered  as  borderland 

153 


154  Diseases  of  the   Breast. 

cases  between  benign  and  malignant  neoplasms.  Myxomat- 
ous tissue,  as  is  well-known,  is  the  lowest  type  of  adult  tissue, 
and  its  existence  as  a  primary  mammary  neoplasm,  of  which  it 
makes  up  the  essential  constituent  element,  seems  to  me  to  rep- 
resent the  connecting  link  between  fibroma  and  sarcoma. 

This  view  is  corroborated  by  the  circumstance  that  myx- 
omatous degeneration  of  benign  tumors  is  often  associated  with, 
or  followed  by,  sarcomatous  changes.  Clinically  the  rapid 
growth  and  not  uncommon  occurrence  of  such  tumors  after 
removal  lends  support  to  this  view.  It  must  not  be  forgotten, 
however,  that  sarcoma  may  undergo  myxomatous  degeneration 
exactly  as  fibroma  does. 

In  regard  to  the  origin  of  the  myxomatous  tissue,  it  may 
be  stated  that  it  develops  in  the  periductal  connective  tissue. 
When  secondary  it  probably  is  produced  as  the  result  of  edema 
in  this  tissue  (Warren). 

Myxomatous  tumors  vary  in  size,  some  being  no  larger 
than  a  hen's  egg,  while  others  are  as  big  as  a  cocoanut.  They 
are  encapsulated  and  lobulated,  and  vary  in  consistence,  some 
being  soft  or  fluctuating  and  others  hard  and  firm.  The 
axillary  glands  are  sometimes  involved.  Occasionally  cysts 
are  found  in  the  substance  of  the  tumor,  particularly  in  those  in 
which  the  myxomatous  process  is  the  result  of  secondary  de- 
generation. 

Treatment  consists  in  amputating  the  breast,  and  also  clear- 
ing out  the  axilla,  if  there  is  any  glandular  involvement.  Re- 
currence is  not  so  apt  to  take  place  as  it  is  in  sarcoma. 


ANGIOMA. 

Angioma  may  affect  not  only  the  integument  of  the  breast 
and  the  subcutaneous  tissue,  but  may  also  occur  as  a  primary 
growth  in  the  substance  of  the  gland  itself.  Although  Klebs 
asserted  that  involvement  of  the  gland  proper  was  always  sec- 
ondary, being  caused  by  extension  of  the  growth  from  super- 
jacent structures,  several  cases  of  undoubted  authenticity  have 
been  reported  in  which  the  tumor  originated  in  the  breast  itself. 

In  regard  to  the  etiology  of  mammary  angioma,  it  may  be 
stated  that  the  tumor  is  always  present  at  birth  or  makes  its 
appearance  during  the  first  weeks  or  months  of  life.  Sex  ap- 
pears to  be  entirely  without  causative  influence.  Cases  have 
been  observed  at  all  periods  of  life  from  infancy  to  old  age. 
Thus  it  is  seen  that  the  tumor  may  remain  of  insignificant  di- 
mensions for  a  long  time  and  then  after  the  lapse  of  years  sud- 
denly begin  to  develop.  In  a  number  of  cases,  however,  it  in- 
creased constantly,  though  slowly,  from  birth,  so  that  it  attained 
a  considerable  size  during  the  early  years  of  childhood.  In 
Althorp's  case  the  affected  breast  had  become  very  much  en- 
larged at  the  seventh  year  of  life,  and  in  one  reported  by  Bajardi 
a  child  two  years  of  age  presented  a  tumor  of  the  right  breast 
as  large  as  a  mandarine. 

Following  injury  these  tumors  not  uncommonly  begin  to 
grow  rapidly,  so  that  one  which  has  been  no  larger  than  a 
walnut  for  years  may  become  as  large  as  an  orange  within  a 
few  months. 

Morbid  Anatomy. — Angioma  of  the  mammary  gland  devel- 
ops in  the  fibrous  stroma  and  interlobular  fat.  The  growth  is 
riddled  with  cavities  varying  much  in  size  and  containing 
blood,  which  may  be  either  liquid  or  inspissated.  Some  may 
be  as  large  as  a  marble  while  others  are  no  bigger  than  the  head 

*55 


156  Diseases  of  the   Breast. 

of  a  pin.  These  cavities  may  be  either  round  or  irregular 
in  shape,  and  are  separated  from  one  another  by  fibrous  or  fibro- 
muscular  septa.  Pressure  of  the  tumor  upon  the  glandular 
structure  causes  atrophy  of  the  latter,  so  that  in  cases  in  which 
the  entire  breast  is  affected  there  may  not  be  a  vestige  of  the 
acini  and  ducts  left.  When  the  tumor  occupies  only  a  portion 
of  the  gland,  however,  normal  elements  are  present  in  the 
parts  not  affected. 

As  a  rule  angiomata  are  not  encapsulated,  although  in  Ba- 
jardi's  case  there  was  a  distinct  fibrous  envelope  around  the 
tumor,  from  which  the  fibrous  septa  between  the  cavernous 
spaces  within  the  growth  were  evidently  derived. 

Cysts  may  also  form  in  angiomata  and  probably  represent 
degenerative  changes.  At  least  this  is  the  view  put  forth  by 
Malapert  and  Morichau-Beauchant,  in  whose  case  there  were 
three  distinct,  separate  cysts  contained  within  the  tumor, 
and  is  one  with  which  I  readily  agree.  The  cysts  may  contain 
serous  or  sanguinolent  fluid. 

When  examined  microscopically  the  vascular  spaces  are 
seen  to  be  filled  with  red  blood-corpuscles.  There  is  also  an 
infiltration  of  leucocytes  at  the  periphery  of  the  septa  dividing 
the  spaces  one  from  another.  Between  the  different  spaces  a 
collection  of  fat-corpuscles  may  be  seen,  and  areas  of  hemor- 
rhage can  sometimes  be  detected  in  the  interstitial  and  fattv 

o 

portions  of  the  growth.  In  a  case  carefully  studied  by  Mala- 
pert and  Morichau-Beauchant  the  acini  in  parts  of  the  gland 
close  to,  but  not  invaded  by,  the  tumor  were  found  to  be  in- 
flamed. There  was  a  decided  proliferation  of  the  epithelium, 
and  some  of  the  acini  were  completely  filled  with  new  cells. 
In  the  same  case  sections  of  the  cyst-wall  were  examined,  and 
it  was  found  to  consist  of  two  distinct  layers.  Blood-vessels 
were  very  numerous.  The  external  layer  of  the  wall  was  in- 
filtrated with  cells  resembling  lymph  cells,  being  round  and  pre- 
senting a  single  large  nucleus,  which  stained  readily  with  hema- 


PLATE  XXI. 


Angioma.     {Sick.) 


Angioma.  159 

toxylin.  These  cells  were  placed  one  upon  another  without  any 
intervening  tissue,  so  that  in  certain  places  they  appeared 
like  minute  nodules.  In  the  interior  of  some  of  these  masses 
cavity  formation  had  already  begun. 

In  Sick's  case  the  tumor  consisted  chiefly  of  connective 
tissue  poor  in  cells  with  little  masses  of  fat  interspersed  through- 
out its  substance.  The  ducts  were  greatly  dilated  and  lined 
by  a  single  layer  of  cylindrical  epithelium.  Veins  and  arteries 
having  normal  walls  were  exceedingly  numerous.  At  certain 
places  they  were  surrounded  by  leucocytes.  Besides  these 
vessels  there  were  many  large  spaces  filled  with  blood-corpus- 
cles. A  few  of  these  dilatations  had  a  wall  composed  of  muscle 
fibers  and  connective  tissue,  whereas  others  showed  merely 
an  epithelial  lining.     (See  Plate  XXI.) 

Symptoms. — Angioma  appears  in  the  breast  as  a  soft,  elastic 
tumor,  which  is  painless  and  not  sensitive  to  pressure.  It 
frequently  pulsates  and  often  becomes  reduced  in  size  under 
pressure,  although  it  resumes  its  former  dimensions  when  the 
pressure  is  removed.  The  gland  is  freely  movable  and  the 
skin  over  it  is  not  adherent.  Not  uncommonly  there  is  a 
dilatation  of  the  cutaneous  veins.  In  Bland  Sutton's  case  the 
skin  became  invaded  by  new  growth  and  ulceration  occurred, 
which  gave  rise  to  some  hemorrhage.  Discoloration  of  the 
skin  has  also  been  observed. 

Violent  exertion,  straining  and  crying  have  been  observed 
to  cause  enlargement  of  the  growth.  The  effect  of  trauma 
has  already  been  mentioned. 

If  cysts  are  present  they  may  make  the  surface  of  the  tumor 
rough  and  uneven  and  may  give  rise  to  fluctuation.  Under 
these  latter  conditions  it  is  evident  that  diagnosis  may  be  ex- 
tremely difficult. 

The  treatment  of  mammary  angioma  consists  in  complete 
removal  of  the  breast.  In  cases  of  areolar  or  subcutaneous 
angioma  excision  of  the  diseased  tissue  may  be  practised. 


ENDOTHELIOMA. 

Among  the  tumors  but  rarely  found  in  the  breast,  although 
comparatively  common  in  the  salivary  glands,  is  endothelioma. 
The  only  case  of  which  the  writer  has  any  knowledge  is  that 
reported  by  J.  Chalmers  DaCosta,  in  1903,  the  pathological  re- 
port upon  which  was  made  by  W.  M.  L.  Coplin.  This  tumor 
was  found  in  a  woman  31  years  of  age  who  had  borne  one  child 
ten  years  previously.  The  tumor  was  10  cm.  in  diameter  and 
had  been  noticed  three  months  previous  to  operation.  It  was 
not  accompanied  by  any  discharge  from  the  nipple  and  caused 
a  dull  ache  only  one  month  prior  to  its  removal.  It  was  located 
near  the  nipple,  the  skin  being  healthy  and  movable  over  it. 
There  was  slight  retraction  of  the  nipple  which  was  more  ap- 
parent than  real.  The  axillary  glands  were  not  enlarged. 
Incision  into  the  growth  was  accompanied  by  more  than  the 
usual  amount  of  hemorrhage. 

Microscopically  it  was  characterized  by  the  formation  of 
large  spaces  with  no  definite  walls,  but  filled  with  closely  packed 
round  or  oblong  cells  of  various  sizes,  having  small,  deeply 
staining  basophilic  nuclei  and  granular  cytoplasm.  Some  of 
the  spaces  contained  blood  in  addition  to  that  contained  in  the 
rather  vascular  stroma.     The  tumor  was  not  encapsulated. 

Prognosis. — Owing  to  the  extreme  rarity  of  this  form  of 
growth  it  is  difficult  to  make  any  definite  statement  upon*  this 
point.  Considering  its  behavior  in  other  organs,  however,  we 
may,  by  analogy,  say  that  total  extirpation  should  be  followed 
by  absolute  cure,  but  that  rapid  recurrence  with  increasing 
tendency  to  malignancy  is  almost  certain  should  removal  be 
incomplete. 

160 


SARCOMA.    , 

Sarcoma  is  one  of  the  rarest  neoplasms  which  affects  the 
mammary  gland,  and  is  not  even  so  common  as  the  older  sur- 
geons, who  stated  that  it  comprised  from  five  to  nine  percent 
of  mammary  tumors,  believed  it  to  be.  No  doubt  the  higher 
percentages  formerly  considered  as  correct  are  attributable  to 
faulty  nomenclature;  for  as  in  the  case  of  the  benign  tumors 
of  the  breast,  so  likewise  as  regards  sarcoma,  there  has  been  an 
inaccuracy  in  the  use  of  terms  employed  to  designate  these 
growths.  As  an  illustration  of  this  error,  it  will  suffice  to  men- 
tion that  even  Tillmanns,  in  the  last  edition  of  his  excellent 
treatise  on  surgery  (Lehrbuch  der  Allgemeinen  und  speciellen 
Chirurgie,  Leipzig,  1904)  speaks  of  cystosarcoma  phyllodes  in 
his  article  on  sarcoma  of  the  breast.  This  tumor,  as  I  have 
already  stated,  is  in  reality  the  papillary  cystadenoma,  it  being 
the  name  applied  to  this  growth  many  years  ago  by  Johannes 
Miiller. 

In  this  connection  it  is  noteworthy  that  Finsterer's  statistics, 
based  on  the  cases  which  came  under  observation  in  Hochen- 
cgg's  clinic  in  Vienna  during  the  last  twenty  years,  give  a  per- 
centage of  six  if  cystosarcoma  phyllodes  be  included,  but  that 
the  percentage  falls  to  three  if  the  latter  be  excluded. 

No  doubt  a  similar  distinction  wrould  decrease  the  percent- 
age in  other  series  of  cases. 

Still  another  way  in  which  an  erroneous  idea  as  to  the 
frequency  of  sarcoma  may  have  gained  ground  is  in  mistaking 
benign  cystic  tumors,  particularly  papillary  cystadenomata,  for 
cystic  sarcomata. 

W.  Roger  Williams,  who  collated  2397  cases  of  tumor  of  the 
breast,  found  that  ninety-four,  or  3.9  percent  were  sarcomata. 
My  own  statistics,  based  upon  a  still  larger  number  of  cases, 
IT  161 


162  Diseases  of  the   Breast. 

show  even  a  lower  percentage.  Thus,  of  5000  cases  of  tumor 
of  the  breast  which  were  collected  from  entirely  trustworthy 
sources,  only  2.78  percent  were  sarcomata.  As  further  illus- 
trating the  rarity  of  this  disease  I  may  mention  incidentally 
that  when  studying  the  age  incidence  of  mammary  sarcoma  I 
was  able  to  collect  only  one  hundred  cases  reported  in  recent 
years  in  which  the  age  of  the  patient  was  stated.  Not  more 
than  one-half  dozen  cases  in  which  the  age  of  the  patient  was 
not  stated  were  found.  My  material  included  the  cases  which 
have  occurred  in  nearly  all  the  large  London  hospitals  during 
the  last  fifteen  years,  or  at  least  all  those  which  appeared  in  the 
official  reports  of  these  institutions.  In  a  recent  analysis  of 
628  cases  of  malignant  tumor  of  the  breast  Sick,  of  Hamburg, 
found  that  only  12,  or  1.9  percent  were  sarcomata. 

The  late  S.  W.  Gross  based  his  classic  paper  on  sarcoma  of 
the  breast  on  one  hundred  and  fifty-six  cases,  which  was  all 
that  he  could  collect  after  a  most  exhaustive  search  through  the 
literature.  He,  however,  considered  the  disease  to  be  much 
more  frequent  than  later  statistics  show  it  to  be. 

Williams  has  also  pointed  out  that  the  relative  liability  of 
the  female  breast  to  sarcoma  is  considerably  below  the  average 
for  the  body  in  general,  9.4  percent  of  the  body  neoplasms 
being  sarcomatous,  whereas  only  3.9  percent,  or  according  to 
my  statistics,  2.78  percent,  of  the  newgrowths  of  the  female 
breast  are  sarcomatous.  In  regard  to  its  comparative  fre- 
quency with  carcinoma  my  statistics  show  that  4001  out  of 
5000  cases  of  tumors  of  the  breast,  or  80.02  percent  were  car- 
cinomata,  whereas  only  138,  or  2.78,  percent  were  sarcomata. 
Thus  it  is  seen  that  carcinoma  is  nearly  thirty  times  as  common 
as  sarcoma. 

In  regard  to  the  etiology  of  sarcoma  little  definite  is  known, 
although  I  am  of  the  opinion  that  traumatism  plays  a  more 
important  role  in  its  production  than  it  does  in  other  mammary 
neoplasms. 


Sarcoma.  163 

The  disease  is  much  more  frequent  in  women  than  in  men. 
In  a  review  of  the  literature  Finsterer  was  able  to  collect  only 
nine  authentic  cases  occurring  in  the  male  sex.  He  reports 
three  others  which  came  to  operation  in  Hochenegg's  clinic 
during  the  thirty  years  from  187 7-1906. 

I  am  of  the  opinion  also  that  some  mammary  sarcomata  owe 
their  origin  to  misplaced  embryonal  tissue  elements,  which 
assume  active  growth  in  adult  life.  When  such  embryonal 
remnants  have  been  deposited  in  the  breast  it  is  very  probable 
that  even  a  slight  injury  may  stimulate  them  to  active  growth. 
Further  investigation  is  required  to  determine  whether  hered- 
ity exerts  any  causative  influence,  or  whether  the  occurrence 
of  carcinoma  in  the  relatives  of  those  affected  with  sarcoma  in 
any  manner  predisposes  to  the  development  of  the  latter  disease. 
It  is  not  known  whether  pregnancy,  lactation,  or  the  involution- 
ary  changes  of  the  breast  exert  a  causative  effect.  In  regard  to 
age  incidence  it  may  be  stated  that  sarcoma  is  unquestionably  a 
disease  of  middle  life,  as  is  graphically  shown  by  the  accom- 
panying chart,  which  is  based  upon  one  hundred  cases  collected 
from  various  sources.  It  has  been  stated  that  sarcoma  in  the 
majority  of  instances  affected  young  women,  and  I  myself 
was  inclined  to  consider  such  to  be  the  case  until  the  above- 
mentioned  collective  investigation  showed  that  one-half  the 
cases  occurred  between  the  ages  of  forty  and  fifty.  It  must 
be  borne  in  mind,  however,  that  the  disease  may  occur  at  any 
age.  The  average  age  incidence  in  Finsterer's  collection  of 
cases  affecting  the  male  breast  was  45.6  years. 

Pathology. — It  has  been  customary  to  distinguish  two 
principal  varieties  of  mammary  sarcoma,  namely,  the  cystic 
or  adenosarcoma  and  the  true  or  pure  sarcoma.  The 
former  originate  in  the  transparent  periductal  tissue,  and 
for  this  reason  I  shall  adopt  the  term  periductal  sarcoma, 
used  by  Warren,  in  preference  to  either  of  the  others  above 
mentioned. 


164 


Diseases  of  the  Breast. 


The  pure  sarcoma  originates  in  the  true  connective  tissue 
stroma  of  the  mamma. 


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FlG.  23. — Showing  the  age  incidence  of  mammary  sarcoma;  based  on 
100  cases  collected  from  various  sources. 


In  regard  to  the  relative  frequency  of  the  two  varieties  the 
statistics  of  Williams  are  interesting 


According  to  his  inves- 


PLATE  XXII 


Sarcoma.    Showing  gross  appearance  of  tumor  and  breast  when 
removed. — (Maurice  H.  Richardson.) 


Sarcoma.  165 

tigations  the  proportion  is  about  80  percent  of  the  periductal 
to  20  percent  of  the  pure  type. 

In  regard  to  the  structure  of  mammary  sarcomata  it  may 
be  said  that  all  forms  occur — -round-celled,  spindle-celled, 
giant-celled,  alveolar  and  melanotic.  Of  the  156  cases  studied 
by  Gross  68  percent  were  said  to  be  spindle-celled  and  5 
percent  giant-celled.  I  believe  that  the  mixed  form,  namely,  a 
combination  of  round  and  spindle  cells,  is  more  common  by 
far  than  any  of  the  others.  It  is  unusual  to  find  a  tumor 
composed  entirely  of  round  or  spindle  cells.  Of  course  one 
or  the  other  may  predominate  and  thus  give  distinction  to 
the  growth.  Ernst  Siebert  states  that  growths  having  a  pre- 
ponderance of  spindle  cells  are  more  common  in  young  women, 
whereas  those  in  which  round  cells  predominate  occur  mostly 
in  women  of  middle  life.  The  average  age  for  the  latter  was 
found  to  be  47 J  years;  for  the  former  36!  years.  Further  in- 
vestigation will  no  doubt  prove  whether  this  age  incidence  will 
hold  good  in  a  larger  number  of  cases. 

That  the  round-celled  sarcomata  are  more  malignant  than 
the  spindle-celled  is  a  matter  of  common  knowledge  among 
surgeons  and  pathologists.  It  grows  more  rapidly  and  not  un- 
commonly proves  fatal  within  three  or  four  months  after  its 
onset.  With  the  exception  of  the  very  rare  melanotic  form, 
it  is  the  most  deadly  which  occurs. 

There  is  a  very  material  difference,  both  as  to  the  microscopic 
and  the  gross  characteristics,  between  the  periductal  sarcoma 
and  pure  sarcoma.  The  former,  as  already  stated,  originate 
in  hyaline  tissue  around  the  ducts,  and  as  a  result  of  their  lo- 
cation it  comes  to  pass  that,  as  the  tumor  increases  in  size, 
the  ducts  become  included  in  the  neoplastic  tissue  by  which 
they  are  compressed  and  distorted,  so  that  clefts,  and  later 
cysts,  are  formed  within  the  substance  of  the  growth.  The 
contents  of  these  cysts,  which  is  often  hemorrhagic,  exudes 
from  the  nipple  in  a  considerable  percentage  of  cases.     From 


166  Diseases  of  the  Breast. 

the  walls  papillary  outgrowths  not  uncommonly  project,  being 
due  to  proliferation  of  the  epithelial  lining.  Glandular  ele- 
ments may  also  be  included  in  the  newgrowth,  the  acini  being 
surrounded  by  sarcomatous  tissue  or  cysts.  It  was  formerly 
believed  that  these  elements  developed  de  novo  in  the  tumor. 
In  the  stroma  of  the  growth  myxomatous  degeneration  is  very 
often  seen,  and  fatty  or  even  calcareous  changes  have  been 
observed.  Fatty  degeneration  if  extensive  imparts  a  yellow 
color  to  the  affected  area. 

The  term  myxosarcoma  is  often  applied  to  those  growths 
in  which  myxomatous  degeneration  is  extensive. 

Cartilage  has  also  been  found  in  mammary  sarcomata. 
This  condition  has  already  been  discussed  under  enchondroma. 

Periductal  sarcomata  appear  in  the  breast  as  round  or  ovoid 
tumors  which  are  clearly  circumscribed  and  somewhat  movable. 
They  are  encapsulated  and  as  cyst-formation  takes  place  become 
distinctly  lobulated.  As  a  rule  they  are  firm  and  indurated  in 
consistency,  although  occasionally  when  large  cysts  are  present 
fluctuation  can  be  detected.  They  vary  in  size,  although  as  a 
rule  they  are  large  when  first  seen  by  the  surgeon.  The  super- 
ficial veins  of  the  breast  are  distended,  the  skin  not  uncommonly 
reddened,  and  as  the  morbid  process  advances  ulceration  is 
wont  to  take  place.  Fungous  sarcomatous  masses  then  pro- 
trude through  the  ulcerations,  and  from  them  hemorrhages  may 
take  place.  In  like  manner  after  the  capsule  has  been  broken 
through,  neighboring  structures  may  be  invaded,  the  morbid 
process  having  been  known  to  advance  to  the  ribs  and  pleura. 

Pure  sarcomata  differ  from  the  periductal  form  in  that  they 
are  usually  smaller,  harder  and  more  regular  in  shape,  and 
that  they  do  not  contain  cysts.  They  are  encapsulated  at 
first,  but  later  may  break  through  the  capsule  and  become  dif- 
fuse. Glandular  and  ductal  elements  arc,  of  course,  not  found 
in    them. 

Symptoms. — During  the  early  stages  of  its  evolution  mam- 


PLATE  XXIII. 


Sarcoma. 


Sarcoma.  169 

mary  sarcoma  gives  rise  to  little  disturbance,  so  that  it  not  un- 
commonly escapes  detection  until  it  has  become  large  enough 
to  attract  the  patient's  attention.  When  first  noticed  it  may  be 
no  larger  than  a  marble  or  a  walnut,  and  as  it  is  painless  and  in 
no  wise  annoys  the  patient,  it  often  happens  that  little  notice  is 
taken  of  it  until  increase  in  size  begins  to  produce  the  fear  that  it 
may  be  cancerous.  Although  cases  have  been  reported  in  which 
the  growth  remained  stationary  for  a  number  of  years,  I  believe 
that  most  mammary  sarcomata  increase  rapidly  in  size.  At  all 
events  a  time  always  arrives  when  rapid  growth  takes  place. 
Pregnancy  invariably  stimulates  them  to  great  activity.  I  re- 
cently saw  a  woman  eight  months  pregnant,  with  apparently  a 
large  sarcoma  growing  from  the  periphery  of  the  axillary  quad- 
rant, which  was  as  large  as  a  small  cocoanut.  At  the  begin- 
ning of  her  pregnancy  it  was,  I  am  told,  no  larger  than  a  small 
walnut.  I  saw  another  case  in  consultation  during  my  resi- 
dence in  Louisville,  Kentucky,  in  a  woman  four  months  preg- 
nant. The  tumor  was  situated  in  the  upper  hemisphere  near 
the  periphery.  Against  my  advice  the  surgeon  removed  only 
the  neoplasm,  leaving  the  gland.  Within  a  month  there  was 
an  enormous  fungating  mass,  and  the  woman  died  at  the  end  of 
the  sixth  month  of  pregnancy. 

Pain  is  variable,  as  a  rule,  being  trivial  or  altogether  absent 
unless  ulceration  takes  place,  when  it  may  become  severe. 
It  has  been  noticed  by  several  observers,  however,  that  the 
tumor  may  become  slightly  painful  before  and  during  the 
catamenia,  and  that  swelling  may  likewise  occur  at  the  time. 

The  general  health  is- usually  not  affected  until  the  disease 
has  become  well  advanced  and  ulceration  occurs.  When  this 
stage  is  reached,  however,  the  patient  becomes  emaciated, 
cachectic,  and  enters  upon  a  rapid  decline.  As  already  stated 
round-cell  sarcoma  usually  proves  fatal  within  a  few  months. 

The  diagnosis  of  large  periductal  sarcomata,  particularly 
those  in  which  cysts  have  formed,  should  present  little  or  no 


170  Diseases  of  the   Breast. 

difficulty.     The    large,    lobulated,    movable    tumor,    with    its 
distended  superficial  veins,  together  with  the  history,  in  most 


Fig.  24. — Sarcoma.     {From  a  photograph  loaned  by  Dr.  W.  B.  Coley.) 

cases  at  least,  of  rapid  increase  in  size,  will  reveal  the  nature 
of  the  disease.     When  ulceration  has  occurred  the  protrusion 


Sarcoma.  171 

of  fungous  sarcomatous  masses  above  referred  to  will  likewise 
make  the  condition  plain.  The  diagnosis  of  small  sarcomata 
may  be  very  difficult  or  even  impossible.  If  discovered  very 
early  in  their  evolution  they  may  be  mistaken  for  the  knot- 
like indurations  of  chronic  mastitis.  From  carcinomata  they  are 
to  be  differentiated  by  the  absence,  as  a  rule,  of  lymphatic 
involvement,  fixation  of  the  skin  and  retromammary  tissues, 
and  retraction  of  the  nipple.  The  nipple,  though  often  displaced, 
is  never  retracted  as  it  is  in  carcinoma.  The  periductal 
fibroma  and  the  fibro-cystadenoma  do  not  grow  so  rapidly 
as  sarcoma,  and  in  the  majority  of  cases  affect  younger  women. 

Prognosis  varies,  depending  upon  the  character  of  the  growth. 
It  is  now  generally  admitted  that  the  periductal  sarcoma  is 
not  so  malignant  as  true  sarcoma  and  that  recurrence  rarely 
takes  place  when  timely  operation  is  practised.  Indeed,  War- 
ren states  that  the  tendency  to  malignancy  in  the  periductal 
sarcoma  is  very  slight.  In  the  Munich  cases  studied  by 
Siebert  internal  metastases  did  not  occur. 

Pure  sarcoma  offers  a  less  favorable  prognosis,  and  many 
cases  of  local  recurrence  as  well  as  metastasis  to  the  internal 
organs  have  been  reported.  As  dissemination  of  the  disease 
takes  place  through  the  blood-vessels  rather  than  through 
the  lymph-channels,  metastases  may  occur  even  when  no  signs 
of  local  recurrence  are  present.  Thus  it  is  that  while  regional 
recurrences  are  much  less  common  than  in  carcinoma,  involve- 
ment of  the  internal  organs  is  more  common.  Metastases 
have  been  found  in  the  long  bones,  the  vertebrae,  the  ribs,  the 
brain,  heart,  lungs,  liver,  pancreas,  ovaries,  and  peritoneum, 
and  in  the  inguinal  and  mesenteric  lymph  glands. 

The  fatal  course  of  the  disease  in  pregnant  women  has 
already  been  alluded  to. 

Treatment  consists  in  complete  excision.  The  breast  should 
invariably  be  amputated,  and  I  also  favor  clearing  out  the  axilla. 
The   necessity  of  the  latter  procedure  has  been  questioned, 


172 


Diseases  of  the   Breast. 


inasmuch  as  the  axillary  glands  are,  as  a  rule,  not  involved. 
Exceptions  to  the  rule,  however,  do  occur,  and  in  view  of  this 
fact  it  is  well  to  remove  the  glands,  especially  as  the  more  com- 
plete operation  will  not  subject  the  patient  to  greater  risk  and 
may  save  her  from  a  recurrence. 

Finsterer  mentions  a  case  from  the  Vienna  clinic  in  which 
it  was  necessary,  four  months  after  removal  of  the  breast,  to 
clear  out  the  axilla  owing  to  involvement  of  the  lymph  glands. 
He  also  mentions  two  cases  in  which  the  supraclavicular 
glands  were  enlarged.  It  is  my  belief  that  a  thorough 
axillary  dissection  should  always  be  made,  as  it  adds  nothing 
to  the  danger  of  the  operation  and  possibly  gives  a  greater 
security  to  any  given  case. 


CARCINOMA. 

Etiology. — We  possess  no  more  knowledge  of  the  primary 
cause  of  carcinoma  of  the  breast  than  we  have  of  its  occurrence 
in  other  organs  of  the  body.  To  discuss  all  the  theories  of  its 
causation  which  have  from  time  to  time  been  propounded  would 
not  be  apposite  to  our  subject,  so  only  those  predisposing  causes 
which  are  generally  recognized  as  being  more  or  less  important, 
together  with  certain  circumstances  which  seem  to  have  a 
bearing  upon  its  incidence  in  the  breast,  will  be  fully  considered. 

In  view  of  the  interest  which  has  of  late  years  been  mani- 
fested in  the  parasitic  or  germ  nature  of  cancer  it  may  not  be 
amiss,  however,  to  discuss  this  subject  before  entering  into  an 
examination  of  the  various  supposed  etiological  factors  of  its 
production  in  the  mammary  gland. 

Many  different  investigators  have  found  minute  spherical 
bodies,  surrounded  by  a  delicate  membrane  and  having  a 
highly  refractive  center,  in  both  the  protoplasm  and  nucleus  of 
carcinoma  cells,  and  some  have  believed  them  to  be  parasites. 
It  yet  remains  to  be  proved  that  they  are  such  or  that  they  are 
in  any  way  related  to  the  production  of  the  disease.  In  1904, 
Doyen  announced  that  he  had  discovered  and  made  cultures 
of  a  germ  which  caused  cancer,  and  to  which  he  applied  the 
name  Micrococcus  neoformans.  Metchnikoff  reported  favora- 
bly, though  not  positively,  upon  Doyen's  assertions.  Other 
reports,  however,  were  entirely  adverse  to  them,  and  at  present 
little  credence  is  given  to  the  result  of  Doyen's  findings. 

Simultaneously  with  the  announcement  of  Doyen's  discovery, 
there  came  a  strong  article  before  the  Surgical  Section  of  the 
International  Congress  at  St.  Louis,  September,  1904,  from 
Professor  Orth,  of  Berlin,  combating  the  germ  theory  of  car- 

173 


174  Diseases  of  the   Breast. 

cinoma,  and  announcing  his  adherence  to  the  cellular  theory 
in  the  most  positive  way.  It  is  very  clear  that  if  parasites  are 
present  they  are  intracellular  and  play  a  secondary  and  not  the 
chief  role  as  an  etiological  factor.  They  certainly  do  not,  and 
according  to  Orth,  it  is  simply  impossible  that  they  should  bear 
the  same  etiological  factor  to  cancer  that  the  bacillus  of  Koch 
does  to  tuberculosis,  and  pyogenic  cocci  to  suppuration.  The 
language  of  Orth  could  not  be  stronger,  and  considering  its 
high  source  is,  therefore,  quoted:  "In  order  to  produce  pus 
or  tuberculosis,  etc.,  it  is  sufficient  for  the  pus  cocci  or  tubercle 
bacilli  to  reach  suitable  media;  to  bring  about  a  secondary 
cancer  it  is  absolutely  necessary  that  cancer  cells  from  the  pri- 
mary or  from  a  similarly  created  secondary  tumor  shall  reach 
the  particular  spot,  and  there  continue  their  growth.  In  the 
case  of  secondary  cancers  we  have  to  do  with  a  successful  trans- 
plantation of  cancer  cells ;  in  the  case  of  pus  foci  or  tuberculosis 
there  occurs  a  transplantation  of  the  parasites,  which  do  not 
themselves  form  the  new  focus,  but  they  impel  the  local  tissue, 
without  any  cooperation  of  the  tissue  of  the  primary  focus,  to 
certain  pathological  changes.  Therefore  there  is  an  important 
difference  between  these  two  classes  of  phenomena;  and  one 
cannot  conclude  that  since,  in  the  case  of  pus  foci,  tuberculo- 
sis, etc.,  parasites  play  a  role,  this  must  also  necessarily  be  the 
case  in  the  carcinomatous  newgrowths.  One  can,  however, 
say  that  if  in  cancer  parasites  should  happen  to  play  a  part, 
then  these  parasites  must  be  of  an  entirely  different  kind  from 
those  above  mentioned,  because  they  must  bear  the  closest 
relation  to  the  cancer  cells  which  characterize  the  growth. 
I  do  not  consider  it  impossible  for  an  intracellular  parasite  to 
play  a  part  here ;  but  it  is  impossible  for  it  to  play  an  indepen- 
dent part.  It  cannot  possibly  in  itself  be  the  decisive  factor  in 
the  newgrowth;  it  cannot  determine  the  variety  and  character 
of  the  newgrowth,  since  the  cells  themselves,  and  only  they  do 
this." 


Carcinoma.  175 

The  transmission  of  a  cancerous  tumor  from  one  individual 
to  another,  though  often  cited  as  evidence  of  the  parasitic  nature 
of  the  disease,  proves  absolutely  nothing  further  than  that  a 
successful  grafting  has  taken  place.  The  tumor  thus  formed 
is  the  result  of  the  multiplication  of  the  cells  introduced  and  is 
analogous  in  every  way  to  epidermis  when  transferred  from  one 
person  to  another,  as  in  skin  grafting.  Until  cultures  from 
the  supposed  germs  can  cause,  alone  and  of  themselves,  indepen- 
dent of  cells,  a  primary  tumor,  it  is  useless  to  insist  upon  the 
infectious  nature  of  the  disease.  Cases  of  so-called  auto-infec- 
tivity  prove  even  less,  for  here  the  host  has  tissues  admittedly 
prone  to  degeneration;  and  it  is  easy  to  understand  how  success- 
ful grafting  can  followjprolonged  contact. 

I  am  not  inclined  to  attribute  much  value  to  the  results 
obtained  by  inoculating  and  grafting  experiments  upon  ani- 
mals, as  mice  for  example. 

The  rare,  if  not  unheard  of  infection,  of  operating  surgeons 
by  cancerous  patients  is  the  strongest  possible  evidence  against 
the  infectious  nature  of  the  disease. 

To  pass  now  from  these  preliminary  considerations  to  a 
study  of  those  conditions  which  bear  upon  the  occurrence  of 
carcinoma  in  the  mammary  gland,  it  may  be  stated  that  sex, 
age,  and  race  undoubtedly  exercise  a  considerable  influence 
over  the  development  of  the  disease.  Thus  the  preponderance 
of  cases  occurring  in  women  is  a  fact  so  firmly  established  that 
no  figures  need  be  adduced  to  confirm  it. 

Not  more  than  one  percent  of  all  cases  occur  in  men.  Out 
of  1460  cases  of  mammary  carcinoma  studied  by  Keyser  only 
10  affected  the  male  breast;  of  307  cases  treated  at  the  Johns 
Hopkins  Hospital,  Warfield  states  that  only  3  were  in  men; 
Fantino  found  only  1  case  in  228,  and  Sick  found  only  2 
in  616.  These  figures  do  not  show  such  a  high  percentage 
among  men  as  those  of  some  of  the  older  authors,  for  instance 
Billroth,  who  stated  the  percentage  to  be  2.82. 


i  ;() 


Diseases  of  the   Breast. 


So,  too,  it  has  long  been  known  that  age  constitutes  an  impor 
tant  etiological  factor,  a  vast  majority  of  all  cases  occurring  in 
women  in  or  past  middle  life,  usually  at  about  the  time  of  the 
climacteric.  Various  statistics,  though  showing  minor  differ- 
ences, are  in  the  main  harmonious  upon  this  point.  Thus, 
for  example,  Gross's,  Williams's  and  Mahler's  analysis  of  cases 


Fig.  2?. — Carcinoma  of  tin-  male  breast. 


all  give  an  average  age  incidence  of  forty-eight  years,  SprengeFs 
show  fifty  years  as  the  most  common  period  of  its  occurrence. 
Gebele's  50.8  years,  and  Sick's  52.3  years.  My  own  statistics, 
presented  graphically  in  the  accompanying  chart,  confirm  pre- 
vious observations,  in  so  far  as  they  show  the  greatest  incidence 
of  the  malady  to  be  in  middle  life.  It  must  be  remembered, 
however,  that  there  are  more  women  living  between  the  ages 


Carcinoma.  177 

of  forty  and  sixty  than  there  are  over  sixty.  If  there  were  as 
many  women  over  sixty  alive  as  there  are  between  forty  or 
forty-five  and  sixty,  I  doubt  not  that  fully  as  great  a  percentage 
of  cases  would  be  found  in  them  as  among  the  others.  It 
will  be  seen  from  the  accompanying  chart  that  21.5  percent 
of  the  5000  cases  were  in  women  past  sixty.  It  will  also 
be  observed  that  the  percentage  of  cases  occurring  in  the 
sixth  decade  of  life  is  1.5  percent  greater  than  those  occurring 
in  the  fifth  decade.  Had  it  been  possible  to  divide  the  entire 
number  of  cases  into  quinquenial  instead  of  decennial  periods,' 
it  is  probable  that  only  a  very  minute  difference,  if  indeed  any 
whatsoever,  would  have  been  found  between  the  periods  from 
forty-five  to  fifty  and  fifty  to  fifty-five. 

The  most  striking  thing  shown  by  the  chart  is  the  sharp  rise 
in  morbidity  which  occurs  after  the  fortieth  year.  The  next 
one,  and  one,  too,  which  is  of  quite  as  great  importance,  is 
that  9  percent,  or  nearly  one-tenth  of  the  entire  5000  cases, 
occurred  in  women  between  the  ages  of  twenty  and  thirty. 
These  latter  figures,  based  as  they  are  upon  a  sufficiently  large 
number  of  cases  to  insure  at  least  a  fair  degree  of  authenticity, 
strengthen  the  view  which  I  had  formerly  often  expressed  rela- 
tive to  the  incidence  of  mammary  carcinoma  in  young  women. 
Between  the  years  1898  and  1906  I  operated  upon  five  cases  of 
cancer  of  the  breast  occurring  in  patients  aged  23,  25,  25,  27, 
and  28  years  respectively.  In  all  but  one  of  these  cases — and 
that  in  the  case  of  the  patient  aged  23  years — the  tumor  was 
a  typical  scirrhus  carcinoma.  McCosh,  Richardson,  Park, 
and  Warren  have  operated  on  patients  aged  19,  21,  22,  and 
22  years  respectively,  and  in  the  Tubingen  cases  analyzed 
by  Mahler  there  was  one  patient  aged  26  years.  These  cir- 
cumstances led  me  to  believe  that  mammary  carcinoma  is 
much  more  common  in  young  women  than  it  is  supposed  to  be, 
and  it  was  rather  for  the  purpose  of  securing  information  on 
this  matter  than  for  corroborating  that  which  has  come  to  be 


1 78 


Diseases  of  the   Breast. 


generally  accepted  regarding  its  most  frequent  occurrence  in 
middle  aged  women  that  I  had  the  age  incidence  of  the  disease 


o 

-.1 

Bol  ween 
20  and  30 
years  of  age. 

Between 
30  and  40 
years  of  age. 

Between 

40  and  50 
years  of  age. 

Between 
50  and  CO 
years  of  ago. 

Over  CO 
year*  of  ago. 

•_'s 

-■: 

_v. 

2."> 

21 

2:3 

22 

21 

20 

lit 

18 

17 

16 

15 

14 

13 

12 

11 

10 

9 

8 

7 

i; 

5 

4 

3 

2 

1 

Fig.  26. — Showing   the   age   incidence   of   mammary   carcinoma;  based  on  5000 
cases  collected  from  various  hospital  reports  and  other  sources. 

investigated  in  a  large  number  of  cases.     The  result  of  this 
investigation,  as  herein  portrayed,  is  significant. 

It  has  been  stated  that  mammary  cancer  affects  the  male 


Carcinoma.  179 

at  a  more  advanced  age  than  the  female.  In  nine  cases  Keyser 
found  the  average  age  to  be  61.5  years.  Williams  states  that 
the  average  age  is  50  years.  The  eight  cases  which  I  have  seen 
were  in  elderly  men.  J.  Chalmers  DaCosta,  however,  has 
seen  two  cases  in  men  under  40  years  of  age.  In  view  of  the 
paucity  of  cases  analyzed,  I  am  of  the  opinion  that  further  inves- 
tigation is  necessary  to  determine  the  difference  in  the  age  inci- 
dence of  the  disease  in  the  two  sexes.  It  is  interesting  to  note 
that  a  case  of  mammary  cancer  occurring  in  a  man  91  years 
old  has  been  reported.  This  is  said  to  be  the  oldest  case  on 
record.  (Lunn,  Trans.  Path.  Soc.  of  London,  Vol.  xlviii.) 

In  regard  to  racial  influence,  it  may  be  said  that  races  such 
as  the  American  negroes  and  Indians,  which  were  formerly 
considered  immune,  have  become  susceptible  since  living  under 
changed  environments.  This  is  especially  true  of  the  negro, 
and  applies  to  carcinoma  of  various  organs,  as  shown  by  my 
investigations  at  the  Louisville  City  Hospital.  In  lesser  degree 
it  is  also  true  of  the  Indian.  All  observers  seem  to  agree  that 
savages  are  peculiarly  exempt  from  cancer,  and  that  Africans 
are  the  most  immune  of  all.  All  early  writers  testified  to  the 
immunity  of  the  Africans  in  their  adopted  country  and,  indeed, 
I  think  it  cannot  be  doubted  that  cancer  was  rare  with  them 
up  to  fifty  years  ago.  These  early  writings,  however,  have  too 
much  influenced  practitioners  of  this  generation,  and  many 
still  believe  that  the  disease  is  rare  among  negroes  because  it 
was  so  a  few  generations  ago. 

Far  from  being  uncommon  in  the  mammary  gland,  carcinoma 
is  as  frequently  met  with  in  American  negroes  as  it  is  in  the 
American  white  races.  I  have  seen  a  dozen  cases  myself. 
The  first  case  of  cancer  of  the  breast  I  ever  saw  was  in  a  negress 
about  forty  years  of  age,  as  black  as  a  crow's  wing.  She  died 
from  recurrence  after  operation,  at  the  usual  time  and  in  the 
usual  way,  confirming  the  clinical  diagnosis.  In  at  least  six 
of  the  other  cases,  too,  the  diagnosis  was  confirmed  both  by 


180  Diseases  of  the   Breast. 

microscopic  examination  of  the  neoplasm  and  the  subsequent 
death  of  the  patient  from  recurrence. 

There  were  839  cases  of  cancer  of  the  breast  reported  in  the 
eleventh  census;  811  females,  28  males.  One  occurred  under  15 
years  of  age;  163  between  15  and  45;  and  670  at  and  over  45; 
rate  of  death  to  100,000  inhabitants:  females  823;  males  0.29; 
age  45  to  65,  30.08;  65  and  over,  50.  Death  rate  practically 
the  same  in  white  and  colored,  being  4.27  in  the  former  and  4.19 
in  the  latter. 

The  records  of  the  Louisville  City  Hospital  for  twenty  years 
show  that  three-fifths  of  the  cases  were  white  and  two-fifths 
colored,  though  the  latter  represent  but  one-third  of  the  Hos- 
pital population. 

I  am  of  the  opinion  that  the  negro,  although  still  enjoying 
a  comparative  immunity  to  carcinoma  in  general,  being  excep- 
tionally free  from  carcinoma  of  the  lip,  tongue,  penis,  etc.,  is 
more  obnoxious  to  cancer  of  the  breast  and  uterus  than  the 
white. 

According  to  W.  Roger  Williams,  who  has  investigated  the 
subject  carefully,  mammary  carcinoma  is  common  in  China. 
He  quotes  Cantlie,  who  states  that  of  114  cases  of  carcinoma 
affecting  Chinese  patients  38  were  mammary,  and  also  states 
that  n  out  of  30  operations  for  malignant  disease  performed 
in  one  year  at  Dr.  Kerr's  Hospital  in  Canton  were  for  neoplasms 
of  the  breast. 

It  has  been  said  that  Jews  are  less  subject  to  carcinoma 
than  other  white  races,  but  this  statement  I  believe  to  be  erro- 
neous. It  certainly  is  not  in  accord  with  the  result  of  observa- 
tions made  in  the  United  States. 

With  the  passing  of  the  constitutional  theory  of  cancer  and 
the  demonstration  and  acceptance  of  its  local  origin  about  thirty- 
five  years  ago,  there  began  a  tendency  to  minimize  the  influence 
of  heredity  as  a  predisposing  cause.  This  tendency  has  been 
carried  too  far,  just  as  has  been  the  case  with  tuberculosis. 


c 


arcinoma.  iei 


The  disease,  of  course,  is  not  inherited,  but  the  soil  is  prepared 
and  made  ready  should  the  seed  be  sown  at  a  time  when  the 
epithelial  tissues  are  prone  to  run  wild.  In  my  own  experience 
at  least  one-third  of  all  cases  which  come  to  operation  have 
been  preceded  by  one  or  more  cases  of  cancer,  usually  of  the 
breast,  in  the  family. 

Delbet,  who  has  studied  this  subject  carefully,  found  from 
analysis  of  a  large  series  of  statistics  that  the  number  of 
cases  in  which  hereditary  influence  was  present  varies  between 
5  and  10  percent. 

Recent  statistics  tend  to  show  that  carcinoma  of  the  breast 
is  more  common  in  married  women,  and  especially  those  who 
have  borne  and  nursed  children,  than  it  is  in  single  women. 
I  cannot  agree  with  those  who  believe  that  it  is  equally  common 
in  the  single  and  married,  the  sterile  and  fruitful. 

Certainly  some  consideration  must  be  given  to  such  results 
as  have  been  derived  from  the  examination  of  hundreds  of 
recorded  cases,  as  for  example  those  analyzed  by  Guleke,  who 
found  that  of  982  patients  treated  in  von  Bergmann's  clinic  90 
percent  had  borne  children.  As  those  familiar  with  the  work 
of  the  late  S.  W.  Gross  may  remember,  he  found  that  316  out  of 
416  women  affected  with  mammary  cancer  had  nursed  children. 

In  view  of  these  and  other  similar  findings,  it  has  been  in- 
ferred that  a  direct  causative  relation  exists  between  the  func- 
tional activity  of  the  gland  and  the  occurrence  of  carcinoma. 
The  periodic  changes  which  take  place  in  the  breast  as  the 
result  of  pregnancy  and  lactation  are  associated  with  evolution 
of  tissue,  which  may  predispose  to  the  proliferation  of  epithel- 
ium in  the  acini,  thereby  leading  to  the  development  of  cancer. 
Perhaps  the  inflammatory  processes  to  which  the  gland  is  often 
subjected  during  the  period  of  lactation  may  lead  to  the  forma- 
tion of  connective  tissue  which  compresses  the  acini,  produces 
irritation,  and  thus  causes  cell  proliferation. 

Granted  that  there  be  a  causative  relation  between  functional 


182  Diseases  of  the   Breast. 

evolution  and  involution  of  the  mamma  and  carcinoma,  there 
yet  remains  a  percentage  of  cases  in  which  this  factor  can  be 
entirely  eliminated.  Every  surgeon  of  experience  has  seen 
cases  of  cancer  of  the  breast  in  maiden  ladies  whose  sexual 
life  has  beyond  any  doubt  been  absolutely  negative.  In  such 
cases  it  would  not  be  illogical  to  infer  that  the  organ  assumes 
morbid  activity  to  compensate  for  the  deprivation  of  normal 
function  which  it  has  sustained. 

Traumatism,  chronic  inflammation,  and  mammary  ab- 
scess have  often  been  cited  as  predisposing  causes.  The  exact 
etiologic  relation,  if  indeed  there  be  any,  which  exists  between 
these  conditions  is  not  known.  Statistics  relative  to  the  influ- 
ence of  mastitis  show  such  wide  variations  that  they  are  totally 
useless.  Thus,  for  example,  Winiwarter  found  a  history  of 
mastitis  in  twenty-four  out  of  one  hundred  and  fourteen  cases, 
whereas  Billroth  obtained  a  similar  history  in  only  seven  out 
of  two  hundred  and  eighty-two  cases.  It  is  interesting  to  note 
that  in  iooo  cases  observed  by  Williams  there  was  only  one  in 
which  the  disease  immediately  followed  injury.  Moreover, 
out  of  137  women  whom  he  interrogated,  only  35,  or  25.5  per- 
cent, gave  a  history  of  antecedent  injury.  Of  course  in  the 
remaining  74.5  percent  there  may  have  been  a  considerable 
number  who  had  received  injuries  which  had  passed  unnoticed 
or  been  forgotten. 

Cancer  of  the  male  breast  seems  to  have  been  associated  with 
injury  in  a  considerable  number  of  cases,  and  in  many  of  these 
the  relation  between  the  traumatism  sustained  and  the  develop- 
ment of  the  disease  has  undoubtedly  been  one  of  cause  and 
effect.  In  two  of  the  eight  cases  which  have  come  under  my 
observation  there  was  a  history  of  traumatism;  one  was  in  a 
shoemaker  who  for  years  had  pressed  a  last  against  his  breast, 
and  the  other  was  in  a  laborer  who  was  in  the  habit  of  resting 
the  handle  of  his  shovel  against  the  breast.  Cases  similar  to 
these  have  been  reported  by  other  surgeons. 


Carcinoma.  183 

Personally,  I  feel  inclined  to  consider  these  factors  as  more 
or  less  influential  in  the  production  of  the  disease,  particularly 
since  all  forms  of  carcinoma  are  generally  found  at  points  sub- 
ject to  persistent  irritation. 

It  has  been  stated  that  the  left  breast  is  more  often  affected 
than  the  right.  Although  I  think  I  have  seen  more  cases  in 
which  the  former  was  affected  than  the  latter,  I  have  never 
believed  that  the  examination  of  a  large  number  of  cases  would 
show  much  difference  as  to  the  frequency  with  which  the  two 


Fig.  27. — Bilateral  mammary  carcinoma. 

breasts  are  attacked.  The  recent  investigations  of  Sick,  of 
Hamburg,  are  very  significant  in  regard  to  this  matter.  He 
found  that  in  2,163  cases  occurring  in  the  practice  of  10  Europ- 
ean surgeons,  the  left  breast  was  affected  1,088  times  and  the 
right  1,075.     The  difference  is  too  small  to  consider. 

The  occurrence  of  carcinoma  in  both  breasts  is  rare,  although 


184  Diseases  of  the   Breast. 

it  is  probably  more  common  than  many  have  been  led  to  believe 
as  the  result  of  individual  experience.  Personally  I  have  seen 
only  two  cases.  A  review  of  the  literature  of  this  subject  has 
been  of  great  interest  to  me,  and  as  some  of  the  statistics  of 
well-known  surgeons  may  not  be  without  interest  to  the  reader, 
I  will  quote  a  number  of  series  of  cases  here. 

Out  of  132  cases  of  mammary  carcinoma  which  came  to 
operation  in  the  Gottingen  surgical  clinic  between  the  years 
1875  and  1885,  Hildebrandt  states  that  there  were  six  in  which 
both  breasts  were  affected.  A  like  number  was  found  out  of  250 
cases  reported  from  Esmarch's  clinic  at  Kiel.  Out  of  228  cases 
operated  on  at  the  Augusta  Hospital  in  Berlin  there  were  only 
two  in  which  both  breasts  were  affected.  In  a  report  of  200 
cases  treated  at  the  General  Hospital  at  Copenhagen  between  the 
years  1870  and  1888  Poulsen  states  that  the  disease  was  present 
in  both  breasts  in  11  cases.  Thus  it  is  seen  that  there  is  no  uni- 
formity as  to  the  percentage  of  cases  in  which  the  disease  is 
bilateral. 

Unfortunately  details  in  regard  to  the  involvement  of  the 
second  breast  are  not  sufficiently  reported  in  these  series 
of  cases  to  permit  a  careful  analysis  to  be  made.  It  would 
be  most  interesting  to  determine  the  average  time  at  which 
disease  appeared  in  the  second  breast  after  the  first  one 
became  affected.  I  have  been  able  to  secure  only  meager 
information  concerning  this  matter.  Albert  describes  a  case 
in  which  both  breasts  were  apparently  affected  simultaneously, 
and  Poulsen  mentions  another  in  which  each  breast  presented 
a  tumor  of  equal  size,  both  of  which  were  said  to  be  of  one  year's 
duration.  Anton  Beck  in  his  Munich  Thesis,  1904,  men- 
tions two  cases  occurring  in  the  service  of  Prof.  Klausner  in 
which  the  tumor  in  each  breast  was  said  by  the  patient  to  have 
appeared  simultaneously;  in  one  of  these  cases  the  growths  were 
of  two  years'  duration,  in  the  other  of  three  months'  duration. 
Thus  it  is  seen  that  there  are  apparently  authentic  cases  in 


PLATE   XXIV 


Adenocarcinoma.— {Maurice  H.  Richardson.) 


Carcinoma.  185 

which  both  breasts  become  diseased  at  the  same  time,  but  of 
course  a  certain  allowance  must  be  made  for  the  accuracy  of  the 
patient's  observation.  In  the  two  cases  of  Klausner  there  was 
a  decided  difference  in  the  size  of  the  tumors  in  the  two  breasts. 
Albert's  case  did  not  come  to  operation  and  so,  of  course,  posi- 
tive data  as  to  the  size  and  nature  of  the  tumors  could  not  be 
obtained. 

While  it  is  of  course  possible  that  the  carcinomatous  process 
might  begin  simultaneously  in  both  breasts,  I  am  of  the  opinion 
that  one  is  always  affected  before  the  other  and  that  the  involve- 
ment of  the  second  breast  is  metastatic,  the  disease  being  con- 
veyed by  the  lympathics.  It  will  be  remembered  that  there  is 
a  set  of  superficial  lymphatics  over  the  sternal  half  of  the  gland 
which  pass  through  the  second  and  fourth  intercostal  spaces  to 
discharge  their  contents  into  the  nodes  of  the  anterior  medias- 
tinum. Some  of  these  vessels  occasionally  interlace  with  those 
of  the  opposite  side,  so  that  virus  from  a  tumor  adherent  to  the 
skin  over  one  breast  might  be  transmitted  to  the  other.  Direct 
permeation  of  the  disease  through  the  fascial  lymphatic  plexus 
might  also  occur. 

The  term  bilateral  carcinoma  has  also  been  applied  to  those 
cases  in  which  recurrence  of  the  disease  took  place  after  ampu- 
tation had  been  performed  and  the  disease  later  developed  in  the 
second  breast,  as  well  as  in  those  in  which  the  second  breast 
became  affected  after  amputation  of  the  first  had  been  per- 
formed and  was  not  followed  by  local  recurrence.  To  the 
frequency  of  the  latter  occurrence  Rotter  has  called  particular 
attention.  Out  of  35  recurrences  he  found  that  6  took  place  in 
the  other  breast.  Late  involvement  of  the  second  breast  is  of 
course  explained  by  transference  of  the  cancer  elements  through 
the  lymphatics. 

In  conclusion,  I  would  plainly  state  that  despite  the  fascinat- 
ing theories  advanced  and  the  information  derived  from  the 
study  of  large  numbers  of  statistics,  I  still  remain  an  agnostic, 


186  Diseases  of  the  Breast. 

denying  that  any  theory  yet  advanced  gives  entire  satisfaction  to 
one  viewing  the  subject  from  a  liberal  point  of  view. 

That  race,  environment,  temperament,  habits,  trauma,  and 
possibly  diet  may  have  some  influence  in  the  etiology  of  cancer 
may  be  allowed,  but  it  would  seem  that  more  than  one  cause 
is  influential,  the  primary  or  essential  causes  yet  remaining 
unknown. 

Pathology. — Carcinoma  can  be  divided  into  adenocarci- 
noma, medullary  and  scirrhus  carcinoma,  carcinoma  simplex, 
gelatinous  carcinoma  and  carcinomatous  cyst.  All  arise  from 
the  epithelium  lining  the  acini,  but  are  classified  under 
different  heads  because  of  the  arrangement  of,  and  the  vary- 
ing relations  of  the  connective  tissue  stroma  to,  the  tumor 
cells. 

Adenocarcinoma  was  first  described  by  Halsted  in  1898, 
and  since  that  time  it  has  come  to  be  recognized  as  a  definite 
pathological  and  clinical  entity.  This  form  of  the  disease 
represents  the  first  step  in  the  deviation  from  typical  epithelial 
proliferation. 

Adenocarcinoma  grows  comparatively  slowly,  but  steadily, 
to  a  rather  large  size,  when  the  skin  breaks  down  and  a  fungating 
mass  is  formed,  which  is  soft  to  the  touch  and  often  overhangs 
the  skin  edge  of  the  growth ;  that  is,  exhibits  a  tendency  to  become 
pedunculated.  This  is  quite  characteristic  of  the  growth.  The 
lymph  nodes  are  rarely  invaded  until  very  late  in  the  disease, 
when  the  tumor  has  been  converted  into  one  of  the  other  forms 
of  carcinoma.  When  enlarged  nodes  have  been  found  in  the 
earlier  stages,  the  enlargement  was  invariably  due  to  endothelial 
hyperplasia. 

On  section  through  the  breast,  the  cut  surface  of  the  tumor 
resembles  the  other  carcinomata,  especially  the  simplex,  being 
softer  than  and  not  quite  so  infiltrating  as  the  scirrhus,  though 
usually  not  quite  so  soft  as  the  medullary  carcinoma.     On  sec- 


PLATE  XXV 


i 


Adenocarcinoma.— (Maur ice  H.  Richardson.) 


PLATE  XXVI. 


Adenocarcinoma.     Microscopic  appearance. 


PLATE  XXVII. 


Section  showing  areas  of  adenocarcinoma  and  medullary  carcinoma. 


PL  ATI-:  XXVIII 


Medullary  Carcinoma.    Showing  appearance  uf  breast  and  tumor  w^eu 
removed.— Olauricc  H.  Biclvardson.) 


Carcinoma.  191 

tion  it  does  not  usually  bulge,  but  some  sections  exhibit  slight 
cupping,  and  on  pressure  extrude  small,  yellowish,  worm-like 
plugs  of  epithelium. 

Microscopically,  typical  portions  of  the  tumor  show  abnormal 
acini  formation,  the  acini  forming  large  tubular  spaces  lined 
with  epithelium,  which,  in  places,  is  very  thick.  As  described 
by  Halsted,  the  cells  in  some  areas  form  combinations  which 
result  in  the  formation  of  gland-like  figures,  circles,  tubes, 
columns  and  minute  papillae.  Even  when  the  tubes  are  com- 
pletely filled  and  there  is  no  lumen,  the  cells  exhibit  the  same 
tendency  to  make  definite  figures  and  cell  combinations.  Some- 
times the  different  figures  anastomose  in  such  a  manner  as  to 
make  a  rather  open  mesh  work. 

The  above  description  applies  only  to  the  typical  portions  of 
the  tumor.  Many  tumors  show  all  stages  and  gradations  from 
the  above  type,  varying  from  sections  closely  resembling  the 
adenomata  to  simplex  and  scirrhus  carcinomata  of  the  most 
atypical  variety.  In  certain  areas,  the  cells  can  be  seen  to  be 
breaking  through  the  basement  membrane  and  entering  the 
connective  tissue  stroma,  to  be  carried  along  in  the  lymph 
spaces,  there  to  set  up  an  atypical  form  of  growth  or  possibly 
become  localized  and  form  a  small  nodule,  the  cells  of  which 
exhibit  the  same  tendency  to  form  figures  as  the  parent  growth. 
Halsted  has  also  described  a  bitypical  form  in  which  the  ordi- 
nary carcinoma  is  seen  to  be  infiltrating  the  stroma  separating 
the  tubes  of  a  typical  adenocarcinoma. 

Although  adenocarcinoma  marks  the  first  step  in  the  deviation 
from  typical  epithelial  proliferation,  it  is  one  of  the  rarer  forms 
of  carcinoma.  As  a  rule  when  atypical  proliferation  of  the 
epithelium  once  begins,  it  loses  all  semblance  to  glandular 
formation  and  multiplies  rapidly  in  preformed  connective 
tissue  or  lymph  spaces,  its  shape  being  determined  by  the 
rapidity  of  the  growth  and  the  space  in  which  it  proliferates. 

These  more  atypical  forms  of  cancer  have  been  divided  into 


k;2  Diseases  of  the   Breast. 

medullary  or  soft  cancer  and  scirrhus  or  hard  cancer.  The 
carcinoma  simplex  is  an  intermediate  form,  not  as  hard  as 
the  scirrhus  nor  as  soft  as  the  medullary.  From  this  it  will 
be  seen  that  the  only  differences  are  based  upon  the  relative 
amounts  of  connective  tissue  and  tumor  tissue  present. 

Macroscopically,  the  medullary  carcinoma  usually  appears 
as  a  large,  soft,  more  or  less  localized  nodule  of  a  pale  or  yellow- 
ish red  hue,  which  may  be  hyperemic  and  may  show  areas  of 
hemorrhage.  It  is  usually  quite  rapid  in  growth  and,  when  it 
approaches  the  skin,  tends  to  ulcerate,  forming  large,  soft, 
flabby  granulations.  Its  borders,  wThile  not  encapsulated, 
ordinarily  can  be  readily  distinguished  from  the  surrounding 
healthy  tissue.  On  section,  the  growth  offers  but  little  resistance 
to  the  passage  of  the  knife,  the  cut  surface  of  the  tumor  bulging 
above  the  surface  of  the  normal  tissue.  On  expression  or 
scraping  with  the  knife,  the  so-called  cancer  juice  may  be  ob- 
tained, consisting  of  the  degenerated  centers  of  the  carcinomat- 
ous cell  nests. 

Microscopically,  the  growth  can  be  seen  to  be  composed  of 
large,  irregular  masses  of  carcinomatous  cells  surrounded  by 
delicate  trabecular  of  connective  tissue.  In  this  form  of  carci- 
noma the  cell  masses  are  more  or  less  polygonal  in  shape,  while 
the  cells  themselves  are  also  irregular,  owing  to  mutual  com- 
pression. The  striking  characteristic  of  the  growth  is  the  great 
preponderance  of  the  epithelium  over  the  connective  tissue 
stroma. 

Owing  to  the  lame  size  of  the  cancer  nests  and  the  small 

o  o 

amount  of  stroma  and  consequently  poor  blood  supply,  the 
centers  of  the  carcinomatous  masses  are  prone  to  degeneration, 
so  that  they  frequently  show  necrotic  cells  in  addition  to  infil- 
trated leucocytes.  The  stroma  of  the  tumor,  especially  at  the 
edge  of  the  mass,  shows  a  definite  round-cell  infiltration. 

Carcinoma  simplex,  occupying  as  it  does  an  intermediate 
position  between  medullary  and  the  scirrhus  carcinoma,  may 


PLATE  XXIX 


Medullary  Carcinomata.    A.  Ulcerating  Tumor.    E.  Section  through  breast 
and  tumor.    [Maurice  II.  Richardson.) 


PLATE  XXX. 


Medullary  carcinoma.     Microscopic  appearance. 


13 


Carcinoma.  195 

resemble  either,  according  to  which  form  predominates  in  the 
microscopical  picture.  It  is,  however,  never  as  soft  as  the 
medullary  nor  quite  as  hard  as  the  scirrhus.  It  usually  exhibits 
more  of  an  infiltrating  appearance  than  does  the  medullary,  re- 
sembling the  scirrhus  in  that  particular. 

Microscopically  it  is  characterized  by  the  more  equal  distri- 
bution of  the  carcinomatous  and  connective  tissue.  The  con- 
nective tissue  trabecular  are  thicker  and  the  cell  nests  smaller. 
The  form  of  the  nests  may  vary,  some  being  polygonal  in  shape, 
as  in  the  medullary,  and  others  forming  wide,  elongated  clefts 
or  tubes,  the  so-called  tubular  carcinoma  of  Billroth.  The  one 
tumor  may  show  three  different  stages  of  growth,  namely, 
medullary,  scirrhus  and  the  intermediate  stage  described 
above.  It  is  much  more  common  than  is  the  true  medullary 
growth. 

Scirrhus  carcinoma  is  characterized  by  contraction  of  the 
stroma  and  atrophy  of  the  epithelium.  The  growth  presents 
as  a  hard,  irregular  mass,  usually  adherent  to  the  skin  and  not 
sharply  outlined.  To  my  students  I  have  often  likened  this 
tumor  when  cut  into  to  an  unripe  pear  or  a  turnip,  so  firm  and 
hard  it  is  and  so  resistant  to  the  knife.  Upon  section  it  creaks, 
a  circumstance  due  to  the  abundance  of  its  stroma.  As  the 
morbid  process  progresses,  adherence  to  the  pectoral  fascia  oc- 
curs, as  the  result  of  which  the  growth  becomes  firmly  fixed  to 
the  thoracic  wall. 

In  scirrhus  there  is  sometimes  an  associated  dense  infiltra- 
tion of  the  skin  around  the  primary  growth  which  may  be- 
come so  extensive  as  to  involve  the  entire  thoracic  wall.  Mi- 
croscopic examination  of  the  thickened,  indurated  integuments 
may  fail  to  reveal  cancer  cells,  although  as  time  passes  the  malig- 
nant nature  of  the  process  is  manifested  by  the  formation  of 
nodules  in  the  skin,  and  in  some  cases  by  ulceration.  This 
condition,  to  which  the  term  cancer  en  cuirasse  is  applied,  has 
long  been  thought  to  be  due  to  invasion  of  the  superficial  lym- 


196  Diseases  of  the  Breast. 

phatic  channels  by  cancer  cells.  Recently,  however,  W.  S. 
Handley,  of  London,  has  compared  it,  in  its  early  stages  at 
least,  with  the  brawny  thickening  of  the  integuments  of  the  arm 
which  often  occurs  in  mammary  carcinoma,  and  asserted  that 
it  is  identical  with  the  pachydermia  which  occurs  in  elephan- 
tiasis. He  believes  the  condition  to  be  dependent  upon  obstruc- 
tion to  the  return  of  lymph  from  the  skin,  which  obstruction 
in  turn  is  due  to  cancerous  permeation  of  the  deep  fascial  lym- 
phatic plexus  or  to  actual  destruction  of  the  vessels  by  perilym- 
phatic fibrosis.  This  theory,  which  is  based  upon  careful 
microscopic  examination  of  tissues  taken  from  the  infiltrated 
thoracic  wall,  is  worthy  of  consideration,  particularly  since  it 
has  been  long  known  that  cancerous  epithelium  may  not  be 
found  even  after  the  most  careful  examination  of  serial  sections 
taken  from  tissues  removed  early  in  the  course  of  the  infiltrative 
process.  It  is  interesting  to  note  that  in  examining  sections  of 
cancer  Handley  has  never  observed  involvement  of  the  deep 
cutaneous  plexus.  He  states,  however,  that  the  dermis  close 
to  subcutaneous  cancer  nodules  is  often  slightly  or  not  at  all 
infiltrated  by  the  growth. 

In  other  cases  of  scirrhus  the  tumor  undergoes  complete 
or  almost  complete  fibrosis.  Here  the  epithelium  is  no  doubt 
destroyed  by  the  constantly  increasing  stroma.  In  some  cases 
of  this  kind  shrinkage  may  takejolace  in  a  well-developed  tumor, 
so  that  only  a  tough,  dense  mass  corresponding  to  what  was 
originally  the  center  of  the  growth  may  remain.  In  other 
cases  in  which  the  formation  of  fibrous  tissue  has  been  more 
rapid  from  the  beginning  than  the  proliferation  of  epithelium, 
a  contraction  of  the  glandular  elements  and  of  the  skin,  which 
is  usually  fixed  to  the  structures  beneath,  is  the  only  morbid 
gross  alteration  perceptible. 

The  results  of  microscopic  examination  of  such  a  scirrhus 
carcinoma,  to  which  the  name  atrophic  or  withering  has  been 
given,  are  in  strict  accord  with  the  macroscopic  characteristics. 


t"LA  I  t:    AAA  I 


(Scirrhus  Carcinoma.— (Maurice  H.  Richardson.) 


PLATE  XXXII. 


Scirrhus  carcinoma.     Microscopic  appearance. 


Carcinoma.  199 

Compact  bundles  of  fibrous  tissue,  with  here  and  there  a  few 
scattered  epithelial  cells,  or  in  some  sections  none  whatsoever, 
are  revealed. 

Naturally  the  dissemination  of  the  malignant  elements  of 
carcinoma  from  such  a  growth  will  be  slower  than  in  the  other 
varieties  of  scirrhus,  just  as  it  is  slower  in  ordinary  scirrhus  than 
in  the  medullary  variety.  For  this  reason  the  course  of  wither- 
ing carinoma  is  very  protracted,  so  that  a  person  affected  with 
it  may  live  for  years.  Allusion  to  this  circumstance  will  be 
made  again  under  the  subject  of  prognosis. 

Gelatinous  carcinoma  (Billroth)  or  mucoid  carcinoma, 
which  is  frequently  incorrectly  called  colloid  carcinoma,  is  a 
very  rare  form  of  cancer  in  which  the  cells  have  undergone 
complete  mucoid  degeneration,  so  that  when  seen  microscopic- 
ally little  more  than  the  connective  tissue  stroma  can  be 
distinguished  surrounding  rather  large  spaces  which  contain 
a  mucoid  material.  Here  and  there  small  clusters  of  a  few 
carcinomatous  cells  can  be  found  undergoing  mucoid  degenera- 
tion. The  growth  shows  very  little  tendency  to  infiltrate,  and 
is  one  of  the  most  benign  of  all  the  carcinomata  of  the  breast. 
It  should  not  be  called  colloid  carcinoma  because  true  colloid 
material  is  not  formed. 

Another  very  rare  form  of  mammary  carcinoma  is  the  car- 
cinomatous cyst,  a  malignant  cystic  tumor  the  walls  of  which 
are  infiltrated  with  carcinomatous  epithelium.  Hard  carcinom- 
atous masses  have  also  been  observed  growing  from  the  inner 
wall  of  the  cyst.  Papillary  excrescences,  however,  are  never 
present,  a  circumstance  which  distinguishes  the  neoplasm  from 
papillary  cystadenoma  which  has  undergone  cancerous  degen- 
eration. Very  frequently  the  carcinomatous  process  extends 
from  the  cyst  wall  to  the  surrounding  tissues,  with  the  result 
that  a  considerable  degree  of  induration  is  produced.  Involve- 
ment of  the  anatomically  associated  lymph  glands  occurs  as 
in  the  other  forms  of  mammary  carcinoma.    A  peculiar  charac- 


200  Diseases  of  the   Breast. 

tistic  of  these  cysts  is  that  the  contents  is  almost  invariably 
bloody. 

Bloodgood,  who  has  studied  the  subject  carefully,  believes 
this  to  be  the  rarest  form  of  cancerous  disease  affecting  the 
breast. 

Carcinomatous  cysts  grow  rapidly,  but  develop  signs  of  malig- 
nancy slowly. 

It  has  already  been  stated  that  carcinoma  may  originate  in 
a  breast  affected  with  chronic  mastitis  (see  page  40).  In  such 
cases  the  macroscopic  appearance  of  the  gland  corresponds  to 
that  of  the  primary  morbid  changes,  and  it  is  only  upon  mi- 
croscopic examination  that  the  carcinomatous  epithelium  is 
found  embedded  in  the  dense  fibrous  stroma.  The  malignant 
process  sometimes  invades  the  surrounding  tissues,  in  which 
case  it  may  be  seen  to  follow  the  lymphatics.  I  recently  am- 
putated a  breast  which  was  riddled  with  small  abscesses,  and 
which  I  took  to  be  tuberculous.  Upon  microscopic  examina- 
tion, however.  Dr.  McFarland  found  no  signs  of  tuberculosis, 
but  "  an  associated  medullary  carcinoma,  growing  without 
stroma,  its  cells  being  mingled  with  the  pus-cells  of  the 
abscess." 

Dr.  McFarland  states  that  this  is  one  of  the  most  interest- 
ing tumors  he  has  ever  seen  (Fig.  28). 

The  dissemination  of  carcinoma  is  one  of  the  most  interest- 
ing subjects  in  pathology,  and  one  also  upon  which  rational  cura- 
tive treatment  must  be  based .  The  increased  percentage  of  cures 
of  mammary  carcinoma  obtained  in  the  last  few  years  is  due 
essentially  to  our  increased  knowledge  of  the  normal  and  patho- 
logic anatomy  of  the  lymphatics  which  drain  the  breast,  or  in 
other  words  to  the  manner  in  which  a  primary  carcinomatous 
focus  in  the  mamma  may  invade  contiguous  and  remote  struc- 
tures of  the  body. 

Three  routes  of  dissemination  will  be  discussed  here:  namely, 
(1)  transference  of  cancerous  cells  directly  through  the 


PLATE   XXXIII 


Gelatinous  Carcinoma.—  (Maurice  H.  Richardson) 


Carcinoma. 


20 1 


main  lymph  channels;  (2)  direct  extension  of  the  carci- 
nomatous process  by  growth  of  cells  along  the  minute 
lymphatic  vessels;  (3)  dissemination  through  the  blood 
current. 

Early  in  the  course  of  mammary  carcinoma  the  anatomically 
associated   lymph   glands   of   the   axilla  become  infected,  the 


Fig.  28. 


-Carcinoma  associated  with  multiple  small  abscesses  of  the 
breast,  the  latter  evidently  being  primary. 


morbid  elements  being  undoubtedly  transmitted  directly  through 
the  main  lymphatic  channels  of  the  breast.  It  will  be  remem- 
bered that  not  only  does  the  main  set  of  superficial  lymphatic 
channels  described  by  Sappey  empty  into  the  axillary  glands, 
but  that  a  deep  set  originating  in  the  mucous  membrane  of 
the  ducts  and  acini  of  the  outer  half  of  the  gland  also  reaches 
the  axilla,  where  it  unites  with  the  superficial  plexus  to  form 


202  Diseases  of  the   Breast. 

an  extensive  network  which  extends  upwards  around  the  axillary 
vein  (see  page  10). 

A  gland  examined  microscopically  during  the  early  period  of 
its  invasion  will  show  a  few  epithelial  cells  in  the  subcapsular 
lymph  sinus  at  the  point  of  entry  of  the  afferent  lymphatic 
vessels  (Stiles).  (See  Plate  XXXIV.)  Gradually  the  process 
of  proliferation  extends  until  finally  the  whole  gland  becomes 
carcinomatous;  if  the  fibrous  capsule  is  broken  through,  as  not 
uncommonly  happens,  the  adjacent  tissues  become  infiltrated 
with  cancer  cells.  Here  gland  and  surrounding  tissue  form  a 
firm  immovable  mass.  Adherence  to  the  integuments,  and 
later  ulceration,  often  occur.  The  different  chains  of  glands 
may  become  infected  one  after  another,  either  by  direct  ad- 
vance of  the  morbid  process  or  by  transference  of  cancer  cells 
through  the  communicating  lymphatic  vessels,  or  in  both  ways. 

Involvement  of  the  axillary  glands  on  the  opposite  side 
is  an  occurrence  of  considerable  frequency,  and  one  which  is 
prone  to  occur  in  late  cases.  It  has  been  customary  to  explain 
this  phenomenon  by  assuming  that  infection  takes  place  through 
the  superficial  lymphatics  which  drain  the  inner  half  of  the 
mamma,  some  of  which  occasionally  interlace  with  those  of 
the  opposite  side.  Handley,  however,  attributes  it  to  involve- 
ment of  the  trunk  lymphatics  of  the  opposite  side,  due  to  per- 
meation of  the  malignant  process  beyond  the  middle  line,  the 
disease  advancing  along  the  minute  vessels  of  the  fascial  lym- 
phatic plexus.  He  believes  involvement  of  the  opposite  breast  to 
take  place  in  the  same  way.  Handley 's  statistics  concerning 
the  occurrence  of  this  phenomenon  are  very  instructive.  Out 
of  422  cases  which  he  studied  involvement  of  the  second  breast 
took  place  in  66,  or  15  percent.  "It  was  present  in  18  percent 
of  the  Middlesex  Hospital  (late)  cases,  and  in  only  5  percent  of 
the  Guy's  Hospital  (early)  cases."  Thus  it  is  seen  to  be  a  late 
occurrence  in  the  life  history  of  the  disease. 

The  supraclavicular  glands  may  become  infected  through 


PLATE  XXXIV. 


Lymph  node  in  which  carcinoma  has  replaced  normal  tissue 
except  at  the  periphery. 


Carcinoma.  205 

the  efferent  lymphatic  channels  from  the  axillary  glands  or  by 
way  of  the  set  of  cutaneous  vessels  recently  described  by  Poir- 
icr  and  Cuneo,  which  drains  the  upper  half  of  the  breast  and 
passes  directly  over  the  clavicle  to  empty  into  the  glands  above 
that  bone. 

The  mediastinal  glands  may  become  implicated  through 
that  set  of  deep  lymphatics  which  drains  the  inner  half  of  the 
breast,  and  after  perforating  the  second  and  fourth  intercostal 
spaces  empty  directly  into  these  glands.  This  set,  moreover, 
is  joined  by  some  superficial  vessels  which  likewise  pour  their 
contents  into  the  mediastinal  glands. 

The  same  changes  which  have  been  described  as  occurring 
in  the  axillary  glands  take  place  in  these.  They  may  become 
so  much  enlarged  as  to  press  the  sternum  forward. 

The  deep  set  of  vessels  just  mentioned  communicate  with  the 
lymphatics  of  the  liver;  hence  invasion  of  this  organ  may  be 
explained  by  reason  of  lymphatic  dissemination.  This  matter 
will  be  referred  to  again  in  discussing  visceral  dissemination. 

Involvement  of  the  spinal  cord  may  also  be  explained  by 
lymphatic  invasion,  the  cancerous  elements  being  transmitted 
by  that  set  of  lymphatics  draining  the  middle  of  the  base  of  the 
mammary  gland  and  the  retromammary  tissues.  A  portion  of 
these  vessels  perforate  the  intercostal  spaces  and  accompany 
the  blood-vessels  to  the  spine. 

Mention  has  already  been  made  of  adherence  of  the  carci- 
nomatous mamma  to  the  pectoral  fascia.  (See  Plate  XXXV.) 
That  lymphatic  involvement  of  the  fascia  may  occur  before  the 
breast  becomes  adherent  to  it  is  a  well-known  fact,  but  one  I 
believe  to  which  too  little  attention  has  been  paid.  Heidenhain, 
however,  called  attention  to  it  as  long  ago  as  1889.  In  twelve 
out  of  eighteen  cases  he  found  cancerous  lymphatics  passing 
from  the  mamma  to  this  fascia. 

The  lymphatics  of  the  pectoral  fascia  are  merely  a  part  of  the 
deep  fascial  lymphatic  plexus  already  described  (see  page  11). 


206  Diseases  of  the   Breast. 

In  addition  to  the  various  results  of  lymphatic  infection  al- 
ready mentioned,  it  is  easy  to  understand  why  involvement  of 
the  inguinal  glands  as  well  as  the  axillary  and  supraclavicular 
occurs,  if  it  be  borne  in  mind  that  the  main  trunks  of  this  plexus 
emptying  into  these  glands  may  become  contaminated  by  way 
of  the  minute  vessels  which  connect  them  as  a  network  with 
the  larger  channels  nearer  the  region  of  the  breast. 

The  fascial  lymphatic  plexus  is  the  anatomical  basis  upon 
which  Handley's  theory  of  permeation,  or  extension  of  the 
carcinomatous  process  by  direct  growth  through  the  minute 
lymphatic  vessels,  is  founded. 

Before  entering  upon  a  discussion  of  this  theory,  however, 
I  shall  say  something  concerning  a  method  of  dissemination 
known  as  retrograde  lymphatic  embolism.  It  has  been  asserted 
that  obstruction  of  a  set  of  lymph  glands  would  result  in  the 
production  of  a  reflux  current  in  the  vessels  emptying  into  them, 
so  that  the  cancerous  elements  would  be  transferred  in  the  op- 
posite direction  and  carried  to  the  glands  of  the  unaffected 
axilla,  the  other  breast,  the  inguinal  region,  etc.  Such  a  sup- 
position I  believe  to  be  untenable  for  the  reason  that  the  lymph 
stream  is  at  its  best  weak,  even  in  the  larger  trunks,  and  partic- 
ularly so  in  the  minute  plexus  into  which  the  branches  of  the 
trunks  divide.  Furthermore  the  circumstance  that  the  larger 
trunks  contain  valves  render  the  occurrence  of  regurgitation 
even  more  improbable. 

Mr.  Handley,  of  London,  who  has  recently  published  a 
complete  report  of  his  studies  on  carcinoma  *  believes  that 
cancer  spreads  in  the  parieties  by  direct  growth  through  the 
vessels  of  the  fascial  lymphatic  plexus,  and  that  the  cancer 
cells  are  not  transmitted  as  emboli  through  the  larger  lym- 
phatic trunks  until  late  in  the  course  of  the  disease.  To  this 
process  he  has  applied  the  term  permeation.     His  researches 

*  Cancer  of  the  Breast  and  its  Operative  Treatment,  John  Murray,  London, 
1906. 


PLATE  XXXV. 


Carcinomatous  invasion  of  the  great  pectoral  muscle. 


Carcinoma.  209 

show  that  secondary  deposits  first  appear  in  the  region  of  the 
primary  focus,  but  that  as  the  disease  progresses  they  occur 
further  and  further  away  from  the  site  of  the  original  neo- 
plasm. In  late  cases  he  often  found  that  though  no  permeated 
lymphatics  could  be  detected  in  the  near  vicinity  of  the  or- 
iginal tumor,  examination  of  long  radial  sections  of  the  skin 
and  subjacent  tissues  revealed  the  presence  of  the  disease, 
which  had  invaded  the  minute  vessels  of  the  fascial  lymphatic 
plexus.  Thus  the  boundary  of  the  malignant  process,  that  is, 
the  microscopic  growing  edge  of  the  carcinoma,  is  found  far 
beyond  the  limit  of  macroscopically  perceptible  disease.  "The 
absence  of  permeated  lymphatics  in  the  area  intervening 
between  the  annular  microscopic  growing  edge  and  the  primary 
neoplasm  is  due  to  the  destruction,  after  a  time,  of  the  cancerous 
permeated  lymphatics  by  the  defensive  process  of  perilymphatic 
fibrosis."  It  was  found,  however,  that  isolated  nodules  in  the 
skin  and  muscles  may  be  present  in  the  area  in  which  lymphatic 
involvement  has  disappeared.  These  lesions  are  attributed  to 
failure  on  the  part  of  the  tissues  to  produce,  at  isolated  points, 
a  protective  zone  of  fibrosis  around  the  lymphatic  vessels. 
Thus,  although  the  permeated  lymphatics  along  which  the 
morbid  process  extended  become  obliterated,  the  isolated  car- 
cinomatous lesions  nevertheless  arise  in  continuity  with  the 
primary  neoplasm. 

Mr.  Handley  also  believes  that  visceral  dissemination 
takes  place  as  the  result  of  permeation  along  the  fine  anasto- 
moses which  connect  the  fascial  lymphatic  plexus  with  the  sub- 
endothelial  lymphatic  plexuses  of  the  pleura  and  peritoneum 
and  with  the  mediastinal  and  portal  glands.  The  cancer 
cells,  he  thinks,  then  escape  into  the  pleural  and  peritoneal 
cavities  and  become  implanted  upon  the  viscera,  in  this  manner 
giving  rise  to  the  metastases  which  have  usually  been  thought 
to  be  due  to  dissemination  through  the  lymph  and  blood  cur- 
rents. 

T4 


2io  Diseases  of  the  Breast. 

This  theory  of  Mr.  Handley's,  particularly  in  so  far  as  it 
relates  to  invasion  of  the  parieties,  seems  to  be  founded  upon 
accurate  observation.  That  extension  of  the  malignant  proc- 
ess along  the  lines  of  the  minute  lymphatic  vessels  is  an  actual 
occurrence,  he  seems  to  have  demonstrated  by  careful  micro- 
scopic study  of  the  diseased  tissues.  Moreover,  it  is  plausible 
that  when  permeation  has  extended  to  the  epigastric  triangle, 
where  only  a  layer  of  fibrous  tissue  separates  the  cancerous 
lymphatics  of  the  deep  fascia  from  the  subserous  fat  beneath, 
still  further  progress  of  the  cancerous  disease  may  take  place- 
through  the  minute  lymphatics  of  the  separating  layer  of  fascia. 

I  am  not,  however,  prepared  to  accept  this  theory  of  visceral 
dissemination  nor  to  adopt  it  in  explanation  of  the  involvement 
of  the  axillary  and  mediastinal  glands  and  the  opposite  breast, 
for  I  believe  that  our  knowledge  of  the  anatomy  of  the  larger 
lymphatic  channels  enables  us  to  explain  not  only  the  inva- 
sion of  the  latter  structures  but  infection  of  the  liver  and  the 
portal  glands  as  well.  Allusion  has  already  been  made  to  the 
fact  that  a  set  of  deep  lymphatics  which  drain  the  inner  half 
of  the  breast  communicate  with  the  lymphatics  of  the  liver. 
This  anatomical  relation  seems  to  me  to  afford  an  adequate 
explanation  of  the  presence  of  cancerous  nodules  in  the  latter 
organ,  particularly  in  cases  in  which  extensive  parietal  invasion 
has  not  occurred  and  in  which  the  pleura  is  found  to  be  free 
from  secondary  deposits.  The  fact  that  the  liver,  as  is  generally 
conceded,  is  the  viscus  most  frequently  affected  by  metastases, 
lends  weight,  I  think,  to  my  belief  that  lymph-embolism  may  be 
held  responsible  for  its  participation  in  the  malignant  process 
originally  beginning  in  the  breast. 

In  this  place  it  is  apposite  to  remark  that  the  old  theory 
of  abdominal  invasion  being  secondary  to  thoracic  involvement 
is  certainly  erroneous.  I  have  seen  cases  in  which  careful 
postmortem  examination  showed  no  thoracic  lesions  whatever 
and   yet   marked   abdominal   disease   was   present.     Handley 


Carcinoma.  211 

also  calls  attention  to  this  fact,  and  his  statistics  concerning  the 
matter  are  most  valuable.  Thus,  out  of  422  cases,  there  were 
70  which  showed  abdominal  metastases,  but  no  thoracic  ones. 
In  many  cases  intrathoracic  growth  is  also  present,  particularly 
enlarged  glands  in  the  mediastinum.  That  detachment  of 
cancer  cells  from  the  secondary  deposits  in  the  liver  may  take 
place  and  result  either  in  infection  of  other  viscera  by  the  blood 
stream  or  by  direct  implantation  upon  neighboring  structures, 
is,  I  believe,  in  the  light  of  our  present  knowledge,  not  to  be 
doubted.  Possibly  direct  growth  from  the  surface  of  the  liver 
to  the  peritoneum  may  lead  to  further  involvement  of  the  ab- 
dominal organs. 

Dissemination  by  the  blood  stream  was  long  considered  to  be 
the  primary  factor  in  the  dissemination  of  mammary  carcinoma. 
Years  ago  when  it  was  thought  that  there  was  a  specific  carci- 
nomatous virus  it  was  customary  to  attribute  the  formation  of 
secondary  deposits  to  the  transmission  of  this  poison  to  the 
affected  organs  by  the  blood  stream.  Such  a  theory,  how- 
ever, finds  no  support  at  present.  It  is  maintained  instead 
that  cancer  cells  detached  either  from  the  primary  or  secondary 
neoplasms  enter  the  veins  and  become  deposited  in  remote  parts 
of  the  body.  It  has  been  supposed  that  the  morbid  growth  in- 
vades the  veins  directly,  first  becoming  attached  to  the  sheath  and 
then  gradually  invading  its  different  coats  until  finally  it  per- 
forates the  intima  and  grows  into  the  lumen  of  the  vessel  as  a 
fungous  mass  from  which  particles  are  detached  and  swept 
away  by  the  blood  stream,  to  be  deposited  in  other  organs  where 
they  serve  as  foci  of  development  for  secondary  neoplasms. 
As  the  small  veins  in  the  vicinity  of  the  primary  growth  are 
often  found  involved  in  the  morbid  process,  and  as  apparently 
trustworthy  observations  have  shown  the  presence  of  these 
embolic  cancerous  masses  in  the  blood-vessels  between  the  pri- 
mary growth  and  secondary  deposits,  it  is  not  surprising  that 
credence  was  given  to  the  theory  of  dissemination  by  direct 


212  Diseases  of  the  Breast. 

invasion  of  the  vascular  system  from  the  original  focus  of  dis- 
ease. So,  too,  its  invasion  indirectly  through  the  lymphatic 
system  by  way  of  the  thoracic  duct  has  been  held  responsible 
for  the  production  of  cancerous  deposits  in  regions  remote  from 
the  breast.  The  thoracic  duct  itself  has  been  found  blocked 
with  cancerous  masses,  and  of  course  in  such  a  condition  it  is 
safe  to  assume  that  particles  of  the  same  substance  would  be 
transmitted  to  the  innominate  vein  and  thence  swept  onward 
by  the  venous  current. 

That  this  method  of  dissemination  may  and  does  occur  I 
do  not  doubt,  but  I  am  not  inclined  to  attribute  so  much  import- 
ance to  it  as  has  been  given  it  by  some  writers.  That  it  may  be 
the  means  of  producing  remote  metastases  late  in  the  course  of 
the  disease  I  am  willing  to  admit  for  want  of  a  better  explanation 
of  their  occurrence,  but  there  are  certain  weak  points  about  the 
theory  which  must  cast  doubt  upon  its  validity.  Thus,  nearly 
twenty  years  ago,  Mr.  Stephen  Paget  pointed  out  that  embo- 
lism is  a  process  which  should  affect  all  organs  alike  and  not 
show  an  affinity  for  certain  ones  to  the  practical  exclusion  of 
certain  others.  He  called  attention  to  the  fact  that  out  of  735 
cases  of  mammary  cancer  there  were  metastases  in  the  liver  in 
241,  whereas  in  only  17  were  there  metastases  in  the  spleen. 
In  340  cases  of  pyemia,  however,  abscess  of  the  liver  occurred 
66  times  and  abscess  of  the  spleen  39  times.  Again,  one  would 
naturally  suppose  that  cancerous  emboli  passing  from  the  great 
veins  in  the  neck  to  the  right  side  of  the  heart  and  thence  to  the 
lungs  would  produce  secondary  growths  in  the  lungs  more  fre- 
quently than  in  more  remote  organs.  It  is  known,  however, 
that  such  is  not  the  case.  Thus,  in  Mr.  Paget's  statistics,  they 
were  affected  in  only  70  out  of  735  cases.  Moreover,  it  is 
well-known  that  carcinoma  originating  in  certain  organs  shows 
a  special  predilection  to  invade  other  organs  with  secondary 
metastases.  The  frequency  with  which  the  bones  are  affected 
in  carcinoma  of  the  breast  and  the  prostate  gland  is  a  matter 


Carcinoma.  213 

of  common  knowledge,  as  is  also  their  almost  complete  immun- 
ity in  carcinoma  of  the  stomach. 

It  is  apparent,  therefore,  that  a  theory  of  mere  mechanical 
distribution  is  not  sufficient  to  completely  account  for  the  for- 
mation of  the  various  metastases.  Mr.  Paget  was  inclined 
to  attribute  a  special  predisposition  of  certain  tissues  and  organs 
to  the  malign  influence  of  the  cancerous  elements.  Roger 
Williams  also  considers  that  some  organs  are  better  able  to  de- 
stroy the  cancer  emboli  than  others.  Such  explanations,  how- 
ever, are  merely  putative,  and  to  my  mind  afford  no  help  in 
enabling  a  better  understanding  of  the  manner  in  which  distant 
metastases  occur. 

That  cancer  cells  are  readily  destroyed  by  the  blood  has  been 
recently  demonstrated  by  M.  B.  Schmidt  (Die  Verbreitungs- 
wege  der  Carcinom).  He  has  shown  that  the  tendency  of  these 
foreign  bodies  is  to  excite  thrombosis,  with  the  result  that  the 
original  nucleus,  that  is,  the  cancer  embolus,  is  destroyed  by 
contraction  of  the  thrombus.  In  view  of  this  liability  of  the 
cancerous  emboli  to  be  destroyed,  I  am  of  the  opinion,  as  already 
stated,  that  the  importance  and  frequency  of  blood-dissemina- 
tion has  been  overestimated.  That  in  some  cases  the  emboli 
survive,  grow  in  the  tissues  in  which  they  are  deposited  and  thus 
produce  secondary  neoplasms, .  I  am  willing  to  admit,  for  I 
believe  that  such  an  occurrence  is  not  only  possible  but  probable. 
In  comparison  with  lymphatic  dissemination,  however,  I  believe 
it  to  be  very  uncommon.  In  conclusion  I  would  state  that  I 
am  not  prepared  to  accept  as  entirely  satisfactory  any  of  the 
theories  of  dissemination  thus  far  advanced,  for  the  reason  that 
there  are  cases  in  which  remote  metastases  occur  which  cannot 
be  adequately  explained  by  any  of  them.  In  other  words  I 
believe  it  yet  remains  to  be  shown  how  certain  secondary 
growths  originate. 

In  regard  to  the  frequency  with  which  various  organs  are 
affected  with  secondary  deposits,  available  statistics  are  not 


214  Diseases  of  the  Breast. 

of  much  value  because  they  are  based  upon  too  small  series  of 
cases.  To  be  of  any  value  in  showing  the  comparative  frequency 
with  which  those  organs  rarely  involved,  such  as  the  thyroid 
gland  and  pancreas  for  instance,  become  affected,  deductions 
should  be  drawn  from  thousands  of  cases,  and  not  from  a  few 
hundred.  Moreover,  the  subject  of  these  rare  metastases  is  of 
no  practical  importance. 

Among  the  organs  most  frequently  affected  are  the  liver, 
the  pleura,  the  lungs,  the  bones,  and  the  brain.  Reference  has 
already  been  made  to  involvement  of  the  liver  through  the 
lymphatics,  it  being  the  viscus  most  commonly  attacked  by 
secondary  deposits. 

The  pleura  may  be  infected  by  direct  growth  from  the  pri- 
mary neoplasm  in  the  breast,  from  the  mediastinum,  from  the 
supraclavicular  glands  by  extension  of  the  growth  directly 
downwards  through  Sibson's  fascia,  and  no  doubt  in  cases  in 
which  the  lungs  are  involved  still  further  dissemination  to  the 
pleura  may  take  place  from  these  latter  organs.  That  the  last- 
named  method  of  dissemination  is  rare,  however,  must  be 
admitted,  the  pleura  usually  being  invaded  before  the  lungs 
are  attacked.  Handley  found  secondary  nodules  on  the  pleura 
in  38  percent  of  422  cases. 

Statistics  relative  to  the  frequency  of  pulmonary  metas- 
tases vary  greatly.  Thus,  for  example,  out  of  423  autopsies 
collected  from  various  sources  Gross  found  the  lungs  affected 
in  49.9  percent,  whereas  Handley  in  422  cases  found  them  in- 
volved in  only  25  percent.  These  figures  certainly  show  the 
futility  of  placing  reliance  upon  statistics  based  upon  a  small 
number  of  cases. 

I  am  inclined  to  attribute  considerable  importance  to  blood- 
embolism  in  the  production  of  metastases  in  the  lungs  on  ac- 
count of  the  fineness  of  the  pulmonary  capillaries. 

The  frequency  with  which  mammary  carcinoma  produces 
metastases  in  the  bones  is  well-known.     The  sternum  and  ribs 


Carcinoma.  215 

may  be  invaded  by  direct  extension  of  the  malignant  process 
from  the  primary  neoplasm.  Attention  should  also  be  called 
to  the  possibility  of  the  humerus  being  invaded  by  direct 
extension  of  the  morbid  process  from  the  axilla. 

The  weight  of  opinion  seems  to  favor  blood-embolism  as 
being  the  cause  of  metastases  in  the  other  bones.  Although 
statistics  show  that  certain  bones,  such  as  the  femur  and  the 
humerus,  are  particularly  liable  to  be  attacked,  I  am  not  inclined 
to  place  much  faith  in  this  supposed  predilection  for  the  reason 
that  autopsies  are  not  complete  as  far  as  examination  of  the 
osseous  system  is  concerned.  In  life  a  cancerous  bone  may  not 
produce  any  symptoms  either  subjective  or  objective  to  lead  the 
patient  or  her  medical  attendant  to  suspect  its  existence,  and, 
therefore,  when  postmortem  examination  is  made  a  careful 
search  for  cancerous  deposits  in  the  bones  is  almost  always 
omitted  from  the  routine  examination.  As  spontaneous  fractures 
of  the  femur  and  humerus  often  occur/and  thus  attract  attention 
to  the  fact  that  lesions  may  be  present  in  the  osseous  system, 
it  is  natural  that  these  bones  should  have  often  been  considered 
the  ones  most  subject  to  metastases.  Certainly  fracture  of 
the  cranial  and  pelvic  bones  and  of  the  scapula  could  not  be 
expected  to  take  place  even  though  they  were  much  affected 
by  cancerous  deposits. 

A  comparison  of  certain  series  of  cases  is  very  interesting 
in  this  respect.  Thus  in  336  necropsies  conducted  by  Torok 
and  Wittelshofer  the  cranial  bones  were  examined  in  nearly 
every  case,  with  the  result  that  they  were  found  diseased  in  33 
cases,  or  9  percent  of  the  total  number.  In  the  combined  cases 
of  Munn  and  Williams,  in  which  the  cranial  bones  were  exam- 
ined only  when  evidence  of  disease  h^d  been  present  during 
life,  they  were  found  affected  in  only  1.8  percent  of  the  cases. 
Statistics  recently  compiled  by  Mr.  Handley  from  the  Mid- 
dlesex Hospital  cases — 329  in  number — seem  to  show  that 
the  bones  nearest  the  primary  neoplasm  are  most  frequently 


216  Diseases  of  the   Breast. 

invaded.  The  clavicle,  however,  showed  an  exception  to  this 
rule.  Moreover,  I  am  inclined  to  believe  that  if  the  sternum 
and  ribs  were  excepted,  and  complete  examination  of  the  other 
bones  made  in  a  large  number  of  cases,  this  rule  might  be  still 
further  invalidated.  As  already  stated,  the  trouble  with  statis- 
tics relating  to  such  subjects  as  the  one  now  under  discussion 
is  that  they  are  based  upon  a  comparatively  meager  series  of 
cases.  I  cannot  but  believe  that  if  routine  examination  of  the 
radius,  ulna,  tibia  and  fibula  were  made  in  a  considerable 
number  of  cases  many  new  instances  in  which  deposits  were 
found  in  them  would  be  added  to  the  isolated  ones  now  on  record. 
Herbert  Snow,  who  examined  the  osseous  system  in  12  unse- 
lected  cases  of  mammary  cancer,  found  fibrotic  induration  in  the 
marrow  of  various  bones;  and,  on  microscopic  examination,  the 
typical  characteristics  of  scirrhus  cancer  were  revealed.  All 
these  9  cases  were  insidious;  no  tumor  of  bone  or  fracture  had 
been  witnessed  during  life  (British  Medical  Journal,  March 
12,  1892). 

In  regard  to  the  site  of  the  deposits  in  the  femur  and  humerus 
it  is  interesting  to  note  that  the  upper  portion  of  the  bone  is 
invariably  attacked.  Handley  states  that  the  base  of  the  great 
trochanter  is  the  point  where  the  morbid  process  begins  in  the 
femur,  but  that  owing  to  the  thickness  of  the  bone  there  fracture 
takes  place  below.  With  increase  of  the  deposit  pressure 
atrophy  occurs,  and  it  is  this  condition,  no  doubt,  which  leads 
to  fracture.  A  free  formation  of  callus  around  the  fracture 
sometimes  results  in  union  of  the  broken  ends  of  the  bone. 

The  vertebrae  are  also  affected  with  comparative  frequency, 
deposits  being  found  in  them  in  9  out  of  the  336  cases  examined 
postmortem  by  Torok  and  Wittelshofer. 

The  brain  and  its  membranes  are  also  probably  more  com- 
monly involved  by  secondary  deposits  than  they  have  been  sup- 
posed to  be.  No  doubt  further  careful  examinations  will  prove 
this  statement  to  be  true,  just  as  I  believe  they  will  show  the 


Carcinoma.  217 

bones  to  be  more  frequently  attacked  than  present  statistics 
show  them  to  be. 

The  pelvic  organs,  according  to  available  statistics,  show 
disease  in  about  5  percent  of  all  cases.  Gross  found  the  uterus 
invaded  in  5.2  percent  of  the  cases  which  he  studied.  In  the 
cases  studied  by  Handley  metastases  were  present  in  the  ovary 
in  4.8  percent  of  the  Middlesex  Hospital  cases,  and  in  8.6  per- 
cent of  the  Guy's  Hospital  cases,  that  is  in  5.6  percent  of 
the  total  number.  In  Guy's  Hospital,  where  the  higher  per- 
centage was  found,  the  average  age  of  the  women  admitted  for 
cancer  of  the  breast  is  considerably  less  than  that  of  the  Middle- 
sex Hospital,  where  there  is  a  ward  for  incurable  cancer  patients. 
Handley  is  of  the  opinion  that  the  greater  frequency  of  ovarian 
metastases  in  the  former  class  shows  that  the  ovary  is  more 
likely  to  become  affected  before  the  menopause  than  after  it, 
that  is,  at  a  time  before  retrograde  structural  changes  take 
place.     This  theory  is  certainly  very  plausible. 

Symptoms.— The  evolution  of  mammary  cancer  is  very 
insidious,  so  that  as  a  rule  its  onset  is  not  marked  by  subjective 
symptoms.  So  slow  may  be  the  growth  of  the  primary  neoplasm 
that  the  patient's  attention  may  not  be  attracted  to  it  until  it  has 
become  of  considerable  size,  when  it  is  discovered  accidentally. 

In  my  experience  the  majority  of  women  affected  with  this 
disease  have  sought  advice  merely  for  the  reason  that  they  have 
found  a  mass  present  in  the  breast,  and  not  because  the  mass 
has  given  rise  to  any  subjective  disturbances.  This  absence  of 
suffering  in  the  earlier  stages  of  the  disease  is  a  circumstance 
which  cannot  be  too  strongly  impressed  upon  the  general  practi- 
tioner, who,  though  he  sees  comparatively  few  cases,  usually 
sees  them  earlier  than  it  is  the  good  fortune  of  the  surgeon  to 
encounter  them.  It  is  equally  important  for  the  physician  to 
impress  upon  female  patients  in  general  the  folly  of  disregarding 
the  presence  of  a  tumor  in  the  breast,  and  particularly  of  con- 
cealing it  from  relatives,   friends,   and  the  family  physician. 


218  Diseases  of  the   Breast. 

•It  is  a  well-known  fact  that  women  who  will  not  delay  in 
seeking  advice  as  soon  as  they  suspect  the  presence  of  an 
abdominal  tumor,  and  who  willingly  submit  to  a  local  and  even 
vaginal  examination,  will  carry  a  tumor  in  the  breast  until  it 
has  advanced  far  beyond  the  stage  of  operability.  Why  this 
is  so  surpasses  the  bounds  of  human  understanding.  In  some 
cases  it  may  be  due,  for  a  considerable  length  of  time  at  least, 
to  the  absence  of  pain  and  soreness  so  characteristic  of  the 
earlier  stages  of  the  disease,  and  as  a  result  of  which  it  may  be 
considered  of  a  trivial  nature.  At  all  events  the  importance 
of  having  patients  consult  a  surgeon  as  soon  as  a  neoplasm  is 
discovered  cannot  be  too  strongly  emphasized. 

Another  explanation  of  this  strange  conduct  on  the  part  of 
women  may  lie  in  the  circumstance  that  tumors  of  the  breast 
are  considered  by  the  laity  as  synonymous  with  cancer  and  that 
cancer  is  believed  to  be  the  equivalent  of  death;  and  that  it  is 
sometimes  due  to  a  desire  of  a  noble,  self-sacrificing  woman 
to  suffer  mutely  rather  than  cause  anguish  to  husband,  children, 
or  family. 

In  still  another  class  of  women  the  fear  of  mutilation  and 
disfigurement  may  be  the  motive  which  restrains  them  from 
revealing  their  infirmity. 

In  fact,  this  disposition  to  conceal  mammary  tumors  is  so 
common  in  all  circles  of  life  that  I  have  come  to  look  upon  it  as 
a  symptom  of  the  disease. 

I  once  treated  an  elderly  woman  for  a  fracture  of  the  left 
humerus;  union  was  surprisingly  slow  in  taking  place,  and 
after  sufficient  callus  had  been  thrown  out  to  make  reason- 
ably good  union,  refracture,  without  traumatism,  suddenly 
occurred. 

The  patient  having  a  cachectic  appearance,  my  suspicions 
were  aroused,  and  when  I  asked  her  if  she  had  uterine  or  other 
disease  she  reluctantly  showed  me  an  advanced  scirrhus  carci- 
noma of  the  mamma,  which  she  had  concealed  from  me  by  re- 


Carcinoma.  219 

fusing  to  expose  the  breast  when  the  fracture-dressings  were 
applied. 

Other  women  have  come  to  me  with  a  tumor  of  the  breast 
which  they  have  carried  for  years,  saying  that  no  one  knew  of  it 
and  requesting  that  I  deny  its  existence  to  their  nearest  relatives. 
Such  a  case  occurred  in  a  maiden  lady  of  about  fifty-five  years 
of  age,  the  daughter  of  a  prominent  surgeon,  the  sister  of  a 
physician,  both  of  whom  she  declined  to  consult.  She  came  to 
my  office  with  a  married  sister,  but  would  not  permit  her  to 
come  into  the  consultation  room  during  the  examination.  She 
presented  a  large  tumor  in  the  right  breast  which  was  evidently 
sarcomatous,  although  it  was  undoubtedly  originally  benign. 
An  immediate  operation  was  advised,  and  although  the  advice 
was  accepted  she  did  not  allow  her  family  to  know  her  condition 
until  she  entered  the  infirmary.  No  local  recurrence  took  place 
but  internal  metastasis  eventually  caused  death.  Metastasis 
to  the  right  femur  was  plainly  visible  in  six  months.  A  large 
tumor  also  developed  in  Scarpa's  triangle. 

A  third  case  I  saw  in  consultation  with  a  former  colleague 
in  Louisville,  Kentucky.  A  most  intelligent  maiden  lady, 
about  fifty  years  of  age,  a  well-known  teacher  in  the  female 
high  school,  and  the  daughter  of  a  former  distinguished  pro- 
fessor of  surgery,  consulted  a  surgeon  for  a  tumor  of  the  breast 
which  she  had  concealed  from  her  sister,  with  whom  she  lived, 
and  to  whom  she  was  greatly  attached.  An  engagement  to 
marry  caused  her  to  seek  surgical  advice,  and  at  the  time  of 
doing  so  the  growth  was  found  so  far  advanced  as  to  be  well- 
nigh  inoperable. 

I  could  mention  other  cases  where  the  concealment  has  been 
practised,  but  these  are  sufficient  to  serve  as  illustrations. 
Similar  cases  have  been  reported  by  other  writers,  notably  by 
Mr.  Sheild,  of  London. 

.  Cancer  of  the  breast  begins  as  a  small  nodule,  usually,  though 
not  always  situated  in  the  upper  outer  quadrant  of  the  gland. 


220  Diseases  of  the   Breast. 

It  gradually  increases  in  size,  is  adherent  to  the  gland,  and  is 
freely  movable  with  the  latter.  It  cannot,  as  a  rule,  be  isolated, 
for  the  reason  that  it  is  intimately  connected  with  the  glandular 
parenchyma.  It  is  hard  and  firm  in  consistency,  and  can  be 
readily  palpated,  although  as  just  stated  no  distinct  line  of 
demarcation  between  healthy  and  diseased  tissue  permits  it  to 
be  distinctly  isolated.  This  diffuse  nature  is  distinctive  of  car- 
cinoma. As  the  morbid  process  advances  the  tumor  becomes 
adherent  to  the  skin  in  front  and  to  the  pectoral  fascia  behind. 
The  skin  loses  its  smoothness  and  softness  and  becomes  slightly 
corrugated.  This  corrugation  is  particularly  noticeable  when 
the  skin  is  picked  up  between  thumb  and  finger  and  slightly 
compressed.  This  appearance  of  the  skin  has  been  likened  by 
French  writers  to  that  of  orange  peel,  and  the  comparison  is  one 
which  is  not  at  all  inappropriate. 

If  the  neoplasm  is  situated  near  the  center  of  the  gland,  retrac- 
tion of  the  nipple  may  take  place,  owing  to  traction  on  the  fibrous 
bands  which  connect  it  with  the  deeper  portions  of  the  gland. 
Gross  observed  this  phenomenon  in  108  out  of  207  cases,  or  in 
a  little  more  than  50  percent.  Thus  it  is  seen  that  the  sign  is 
far  from  constant,  so  that  too  much  dependence  must  not  be 
placed  upon  it.  It  was  formerly  considered  one  of  the  cardinal 
signs  of  malignancy,  but  we  now  know  that  such  is  not  the  case 
(see  Fig.  29). 

Later  in  the  course  of  the  disease  firm  fixation  of  the  breast 
to  the  pectoral  fascia  occurs,  or  the  substance  of  the  muscle 
itself  becomes  invaded.  If  the  arm  be  abducted  so  as  to  put 
the  Dectoral  muscles  on  the  stretch,  it  will  be  found  that  the 
breast  will  not  move  in  the  direction  of  the  muscle-fibers ;  when 
the  arm  is  adducted  again  so  that  the  muscles  are  relaxed, 
the  breast  then  moves  with  them.  At  an  earlier  stage  of  adher- 
ence partial  fixation  to  the  deep  fascia  may  be  demonstrated 
by  abducting  the  arm  and  then  moving  the  breast  up  and  down 
and  from  side  to  side  with  one  hand  while  the  elbow  is  held 


c 


arcinoma. 


221 


with  the  other  and  the  patient  makes  an  effort  to  carry  her 
arm  to  the  side  of  the  body.  During  these  manipulations  it 
can  be  readily  determined  whether  the  mobility  of  the  gland  is 
diminished. 


Fig.  29. — Scirrhus  carcinoma.     Note  retraction  of  the  nipple. 


Women  presenting  all  these  signs  may  feel  perfectly  well 
and  look  strong  and  healthy,  a  circumstance  which  goes  far  to 
prove  that  mammary  cancer  per  se  is  a  strictly  local  affection. 


222  Diseases  of  the   Breast. 

Adherence  of  the  skin  may  in  time  be  followed  by  ulceration, 
but  as  a  rule  the  latter  occurs  late  in  the  course  of  the  disease. 

Dissemination  of  the  cancer  virus  through  the  lymphatics 
undoubtedly  begins  at  a  comparatively  early  period  in  the  evo- 


Fig.  30. — Typical  scirrhus  carcinoma  of  the  upper  and  inner  quadrant  of  the  breast. 


lution  of  the  neoplasm,  with  the  result  that  the  lymph  glands, 
which  receive  lymph  from  the  channels  passing  through  the 
breast,  become  diseased.  Those  in  the  axilla  usually  first 
show  signs  of  involvement,  and  then  those  in  the  subclavian 


Carcinoma.  223 

triangle.  In  a  patient  whom  I  recently  operated  upon  two  en- 
larged glands  were  found  between  the  pectoral  muscles.  This 
was  the  first  case  in  which  I  had  observed  enlargement  of  these 
glands,  although  I  had  read  of  instances  in  which  they  had 
been  found  (Rotter,  Grossmann). 

In  regard  to  the  exact  time  at  which  glandular  involvement 
occurs,  it  may  be  stated  that  statistics  show  that  palpable 
enlargement  may  be  demonstrated  between  the  eleventh  and  . 
eighteenth  months.  Such  statistics  are  of  very  little,  if  any, 
value  for  the  reason  that  glands  may  be  diseased  and  still  not 
be  perceptibly  enlarged.  Much^credit  is  due  to  Gross,  Banks, 
Gussenbauer,  Kermisson,  and  a  number  of  other  surgeons 
who  first  called  attention  to  this  fact.  It  is  a  matter  which  the 
general  practitioner  should  not  fail  to  remember.  By  bearing 
it  in  mind  he  may  be  led  to  refer  cases  to  the  surgeon  which 
otherwise  he  might  keep  under  observation  for  a  longer  period, 
to  the  manifest  detriment  of  the  patient. 

Bull's  statistics  show  that  65  percent  of  all  patients  present 
signs  of  palpable  enlargement  of  the  axillary  glands  when  first 
seen  by  the  surgeon,  and  I  believe  it  would  be  safe  to  say 
that  even  a  higher  percentage  are  thus  affected,  as  at  operation, 
however  early  it  may  be  performed,  there  will  almost  invariably 
be  found  metastases  to  the  lymph  nodes.  In  but  a  single  case 
have  I  failed  to  demonstrate  it. 

The  glands  which  first  become  palpably  enlarged  are,  as  a 
rule,  those  along  the  external  margin  of  the  great  pectoral 
muscle.  They  may  be  readily  felt  by  insinuating  the  finger- 
tips beneath  the  lower  portion  of  the  anterior  axillary  wall  and 
running  them  up  and  down  along  the  borders  of  the  muscle. 

As  the  disease  makes  greater  and  greater  inroads  the  local 
condition  becomes  much  more  appalling  in  appearance.  As 
already  stated  ulceration  frequently  follows  adherence  to  the 
skin.  The  tumor  becomes  livid  and  purple,  the  veins  dilated, 
the  skin  perforated,  and  a  fissure  forms  which  becomes  larger 


224  Diseases  of  the   Breast. 

and  larger,  its  edges  become  everted  and  somewhat  under- 
mined, although  their  base  is  hard  and  firm.  From  this  sur- 
face a  purulent,  malodorous  discharge  is  given  off,  and  as  the 
ulcerative  process  encroaches  more  and  more  upon  the  con- 
tiguous areas  of  the  breast,  hemorrhages  may  occur,  owing  to 
erosion  of  the  vessels.  Though  usually  slight  they  may  occa- 
sionally be  so  severe  as  to  alarm  both  patient  and  physician. 
The  ulcerative  process  may  also  extend  to  the  axilla.  In  ad- 
dition to  these  ulcerative  changes  in  the  breast  and  axilla 
subcutaneous  cancer  nodules  may  be  present  in  various  por- 
tions of  the  thoracic  wall,  in  some  cases  being  confined  to 
the  regions  adjoining  the  breast,  in  others  extending  over  a  wide 
area.  They  have  been  known  to  invade  the  shoulder,  the  back, 
and  the  abdomen;  they  not  uncommonly  undergo  ulceration  in 
these  remote  areas,  but  as  a  rule  it  is  those  near  the  primary 
neoplasm  which  show  this  change. 

With  the  supervention  of  these  extensive  local  disturbances 
the  general  health  manifests  signs  of  impairment.  The  patient 
loses  flesh  and  strength,  and  enters  upon  a  decline  which  has  an 
invariably  fatal  progression.  The  ulceration  becomes  more 
extensive,  the  secretion  more  abundant,  the  hemorrhages  more 
frequent  and  more  profuse.  Owing  to  compression  of  the 
axillary  vein  edema  of  the  upper  extremity  may  supervene, 
although  this  symptom  is  not  very  frequent.  I  doubt  if  I 
have  observed  it  in  more,  than  5  percent  of  my  late  cases. 
The  cachectic  appearance  and  extreme  emaciation  presented 
by  the  unfortunate  subjects  of  advanced  cancer  is  so  well- 
known  that  it  would  be  futile  to  portray  it  in  detail.  Happily 
they  are  not  seen  as  often  now-a-days  as  they  were  in  the  past. 
Before  death  puts  an  end  to  the  suffering  of  these  patients 
signs  of  generalization  of  their  disease  usually  plainly  manifest 
themselves.  Thus  nodules  in  the  liver  or  uterus  may  be  palpated, 
spontaneous  fractures  occur,  or  signs  of  pulmonary  metastases 
break  out.     Pleural  effusion  may  occur,  although  in  my  expe- 


PLATE  XXXVI 


Large  funeratintr  carcinoma  cf  the  breast. 


Carcinoma.  225 

rience  it  is  one  of  the  rarest  complications.  Allusion  has 
already  been  made  to  the  occurrence  of  paraplegia,  owing  to 
dissemination  of  the  disease  to  the  spinal  column  by  way  of 
the  lymphatics.  This  is  a  late  symptom  also,  and  one  which 
I  have  not  often  seen. 

There  is  considerable  difference  in  the  mode  of  evolution  and 
duration  of  the  various  forms  of  cancer  of  the  breast,  and  al- 
though these  differences  have  been  described  under  pathology 
it  may  not  be  amiss  to  say  something  concerning  them  here,  and 
particularly  to  call  attention  to  the  rare,  so-called  acute  form  of 
cancer. 

Thus  it  is  apparent  that  ulceration  will  take  place  earlier 
in  the  encephaloid  forms  than  in  scirrhus,  in  which  the  ten- 
dency to  contraction  is  so  great.  It  is  in  ulcerating  carcino- 
mata  of  this  form  that  fungous  masses,  such  as  are  shown  in 
Plate  XXXVI,  develop.  Naturally  such  a  tumor  will  destroy 
life  in  a  shorter  time  than  will  ordinary  scirrhus. 

The  tendency  to  early  ulceration  in  adenocarcinoma  has 
already  been  alluded  to. 

The  slow  progress  which  atrophic  scirrhus  makes  has  al- 
ready been  mentioned .  under  pathology.  The  most  marked 
characteristic  of  this  iorm  is  its  invariable  tendency  to  produce 
contraction  of  the  tissues.  It  often  produces  a  decided  de- 
pression of  the  surface  of  the  breast,  so  great  is  the  contraction 
of  the  tissues  beneath.  In  fact  the  breast  affected  is  much 
smaller  than  its  fellow.  In  a  case  recently  operated  upon 
the  cancerous  breast  was  less  than  half  the  size  of  the  healthy 
mamma.  The  nipple  may  be  so  retracted  as  to  be  scarcely  per- 
ceptible. Ulceration  occurs  only  after  years,  if  indeed  it  happen 
at  all.  Despite  the  slow  evolution  of  the  malignant  process, 
it  is  always  progressive.  Patients  may  live  for  ten,  twelve, 
or  fifteen  years,  however,  before  they  succumb.  It  may  be 
well  to  emphasize  in  this  place  the  fallacy  of  allowing  patients 
affected  with  this  form  of  mammary  cancer  to  go  on  from 
15 


226 


Diseases  of  the   Breast. 


year  to  year  without  operation.  The  slowness  of  its  growth 
and  its  comparative  benignity  constitute  good  reasons  for  suc- 
cessful removal  of  the  affected  tissues  and  the  eradication  of 


Fig.  31. — Atrophic  or  withering  scirrhus.     Observe  the  complete  disappear- 
ance of  the  nipple  and  shrinkage  of  the  breast. 


the  morbific  elements    which  spread    therefrom.     It  is   cer- 
tainly reprehensible  not  to  operate  in  cases  of  this  kind  as  soon 
as  the  diagnosis  is  made.     (See  Fig.  31.) 
The  so-called  acute  cancer  which  has  been  described  by 


& 


arcinoma. 


227 


Billroth,  Volkmann,  Paget,  Gross  and  a  few  later  writers, 
notably  Delbet,  may  destroy  life  within  a  few  months  after  its 
onset.  This  form  of  the  disease,  which  is  fortunately  rare, 
often  begins  during  pregnancy  or  lactation  and  so  rapidly 
involves  the  entire  gland  that  it  may  well  be  referred  to  as  car- 
cinomatous mastitis,  as  suggested  by  Volkmann.     The  affected 


Fig.  32. — Advanced  carcinoma. 

breast  begins  to  increase  in  size  without  any  subjective  dis- 
turbances being  experienced  by  the  patient.  The  enlargement 
is  diffuse  in  contradistinction  to  that  which  characterizes  the 
ordinary  forms  of  mammary  cancer;  consequently  upon  palpa- 
tion no  distinct  mass  can  be  outlined  in  the  breast,  the  organ 
being  enlarged  in  its  entirety  and  being  firm  and  hard  to  the 
touch.    The  skin  soon  becomes  reddened  and  adherent,  and  ul- 


228 


Diseases  of  the   Breast. 


ceration  quickly  supervenes.  Pronounced  cachexia  early  mani- 
fests itself,  and  the  patient  dies  from  exhaustion  or  possibly 
from  repeated  hemorrhage  from  the  ulcerated  areas  of  the  breast. 
Remarkable  instances  in  which  both  breasts  have  been  attacked 
have  been  reported.  One  of  the  most  interesting  cases  of  this 
kind  which  I  have  found  is  one  reported  by  Billroth.     It  was 


Fig.  33. — Inoperable  carcinoma. 


that  of  a  lady  who  was  attacked  five  weeks  before  deliver}7  of 
her  eighth  child,  and  who  died  seven  days  after  an  easy  and 
natural  labor.  Postmortem  examination  revealed  metastases 
in  the  liver,  kidneys,  omentum,  thyroid  gland,  and  pericardium. 
Both  breasts  were  enormously  enlarged,  although  the  entire 


Carcinoma.  229 

duration  of  the  disease  as  noticed  by  the  patient  was  only  six 
weeks. 

Another  interesting  case  observed  by  the  late  S.  W.  Gross, 
and  also  affecting  a  pregnant  woman,  was  one  in  which  the 
disease  apparently  began  as  a  nodule  in  the  sternal  portion  of 
the  mamma,  and  then  within  two  weeks  had  diffused  itself 


Fig.  34. — Inoperable  carcinoma.     Showing  enlarged  glands  in  right  axilla  in 
left  sided  mammary  disease. 

throughout  the  substance  of  the  gland.  Gross,  who  saw  the 
patient  three  months  after  the  first  manifestations  of  her  disease, 
found  the  breast  firmly  adherent  to  the  chest- wall ;  the  skin  adhe- 
rent to  the  breast,  and  thick,  hard  and  brawny;  the  axillary 


230  Diseases  of  the  Breast. 

glands  extensively  diseased,  and  the  supraclavicular  glands  also 
involved. 

This  case  seems  to  indicate  that  the  disease  may  occasionally 
at  least  be  discrete  in  its  inception,  but  even  though  this  cir- 
cumstance be  correct  it  is  not  important,  for  the  reason  that 
the  progress  of  the  disease  is  so  rapid  that  it  soon  assumes  a 
diffuse  character. 

In  a  case  reported  by  Klotz  the  patient  succumbed  three 
months  after  the  onset  of  the  disease;  and  in  another  recorded 
by  Schmidt  six  months  after  its  beginning. 

Although  frequently  associated  with  pregnancy  and  lacta- 
tion, acute  mammary  carcinoma  may  develop  independently 
thereof.  Thus,  of  four  cases  which  have  come  under  the  obser- 
vation of  Delbet,  two  occurred  irrespective  of  pregnancy,  one 
during  pregnancy,  and  one  during  lactation.  Schmidt  also 
observed  a  case  in  a  non-pregnant  and  non-lactating  woman. 

The  peculiar  mode  of  onset  and  evolution  of  this  form  of 
mammary  carcinoma  together  with  its  rarity,  has  very  naturally 
resulted  in  its  being  mistaken  for  other  diseases,  particularly 
abscess  and  sarcoma.  Of  course,  as  it  progresses,  differentiation 
from  abscess  can  be  readily  made,  but  distinction  from  sarcoma 
is  not  so  easy.  In  view  of  its  rapidly  fatal  course  every  case  in 
which  its  presence  is  suspected  should  be  considered  operative 
and  at  once  referred  to  the  surgeon. 

The  clinical  aspect  of  cancer  en  cuirasse,  a  form  the  path- 
ology of  which  has  already  been  discussed  sufficiently  to  im- 
part a  fair  idea  of  the  ravages  which  it  may  produce,  is  one  of 
the  most  terrible  afforded  by  any  variety  of  cancerous  disease  to 
which  the  mammary  gland  is  subject. 

Velpeau,  who  gave  the  first  accurate  description  of  this 
variety  of  the  disease  in  the  year  1838,  related  the  case  of  a 
lady  whose  suffering  was  so  great  that  she  begged  to  be  given 
a  poisonous  dose  of  opium  that  she  might  be  relieved  of  her 
misery  by  death.     Cases  equally  distressing  have  been  ob- 


PLATE  XXXVII 


Cancer  en  cuirasse. 


Carcinoma.  231 

served  since  by  many  surgeons  whose  experience  with  the  dis- 
ease has  been  considerable. 

In  some  instances  the  lesions  affecting  the  thoracic  wall  may 
appear  before  any  tumor  in  the  breast  has  been  detected,  but  as 
a  rule  there  is  a  mammary  neoplasm  present  before  the  changes 
in  the  skin  over  the  mammary  and  pectoral  regions  manifest 
themselves.  They  may  also  first  appear  after  the  diseased 
breast  has  been  removed.  That  these  variations  in  the  onset  of 
the  disease  exist,  will  not  be  confusing  if  the  pathology  be  borne 
in  mind,  particularly  Handley's  theory  of  permeation  through 
the  deep  fascial  lymphatic  plexus;  and,  likewise,  if  individual 
differences  in  the  power  of  resistance  to  disease  be  considered. 

Whatever  may  be  its  chronological  relation  to  the  mammary 
neoplasm,  the  first  manifestations  of  the  disease  make  their 
appearance  as  red  spots  in  the  skin  over  or  near  one  or  both 
breasts.  These  spots  gradually  thicken  until  they  become  con- 
verted into  disc-like  nodules,  varying  in  size  from  a  pinhead  to 
a  filbert.  As  ordinarily  observed  in  the  earlier  stages  of 
the  malady  they  are  about  the  size  of  a  split  pea  or  a  coffee 
bean.  It  is  not  unusual  for  them  to  give  rise  to  an  itching 
or  burning  sensation  as  they  continue  to  enlarge.  As  a  result 
of  the  scratching  and  rubbing  resorted  to  by  the  patient  to  re- 
lieve these  sensations  eczema  may  be  found  associated  with  the 
lenticular  lesions. 

Some  of  these  thickened  spots  may  be  distinctly  elevated, 
so  that  they  resemble  tubercles;  others,  however,  may  be  de- 
pressed. 

There  is  a  tendency  for  the  discrete  lesions  to  become  con- 
fluent, the  nodules  becoming  aggregated  into  patches,  or  some 
being  arranged  in  linear  series.  Pari  passu  with  these  changes 
there  occurs  a  dense,  brawny  infiltration  of  the  remaining  mam- 
mary and  adjoining  tissues,  which  may  extend  upwards  as  high 
as  the  clavicle,  downwards  onto  the  abdominal  wall,  and  later- 
ally as  far  as  the  posterior  margin  of  the  axilla.     The  veins  be- 


2^2  Diseases  of  the   Breast. 

come  dilated,  areas  of  melanotic  deposit  are  formed,  and  in 
some  cases  pearl-like  miliary  bodies  are  observed  here  and 
there  over  the  affected  surface. 

The  infiltrated  tissues  may  assume  a  dusky  or  even  a  brown 
hue.  Yelpeau  compared  the  skin  thus  affected  to  leather,  and 
Erichsen,  who  had  observed  certain  portions  of  the  infiltrated 
areas  covered  with  crusts,  likened  it  to  the  bark  of  a  tree. 

It  is  stated  that  ulceration  may  also  occur,  and  hemor- 
rhages of  varying  degree  have  resulted  from  erosion  of  super- 
ficial blood-vessels.  In  the  many  cases  I  have  seen  ulceration 
has  rarely  if  ever  been  observed. 

In  regard  to  the  age  incidence  of  this  form  of  cancer  I  find 
that  it  may  affect  women  at  all  periods  of  life.  Concerning 
its  predilection  for  the  dark-skinned  I  have  not  been  able  to 
obtain  any  information.  I  am  inclined  to  consider  it  merely 
fortuitous  that  nearly  all  my  own  patients  were  brunettes. 

Almost  always  there  is  great  swelling  of  the  upper  extremity, 
which  gives  rise  to  much  pain.  The  most  distressing  symptom, 
however,  is  the  compression  of  the  thorax  produced  by  the  super- 
jacent infiltrated  tissues.  This  compression  may  not  only  be 
so  great  as  to  interfere  with  the  ordinary  movements  of  the  chest 
and  arms,  but  also  to  impede  respiration,  fastening  the  unfort- 
unate patient  in  a  vice,  so  to  speak. 

The  extension  of  the  malignant  process  is  in  some  cases 
very  rapid,  as,  for  example,  in  one  reported  by  Esmarch,  in 
which  its  progress  was  so  rapid  on  portions  of  the  chest  as  to  re- 
mind one  of  lymphangitis  or  erysipelas.  Such  a  mode  of  ex 
tension,  however,  must  be  unusual.  As  a  rule  the  disease  ad- 
vances at  a  moderate  rate,  although  it  usually  destroys  life 
within  twelve  or  eighteen  months.  I  know  of  one  case  in  which 
the  patient  lived  two  years  and  a  half  after  first  noticing  the 
disease. 

The  very  nature  of  this  affection  unfortunately  renders 
operative  treatment  futile.     In  those  of  my  cases  which  came 


PLATE    XXXVIII 


J 


Cancer  en  cuirasse.    Observe  recurrence  in 
the  cicatrix  and  the  nodule  above  the  clavicle. 


PLATE  XXXIX. 


Inoperable  carcinoma.     Large  fungating  mass. 


Carcinoma, 


235 


to  autopsy  internal  metastases  were  invariably  present  in  ad- 
dition to  the  extensive  superficial  cancerous  lesions. 

Diagnosis  and  Prognosis.— As  I  have  pointed  out  on  several 
occasions,  whatever  better  results  may  be  obtained  from  the 
operative  treatment  of  mammary  carcinoma  will  depend  upon 
earlier  and  more  accurate  diagnosis  rather  than  upon  improve- 
ments in  technique  or  more  extensive  procedures. 

If  the  general  practitioner,  who  as  a  rule  first  sees  the  cases, 
could  be  taught  to  remember  that  80  percent  of  all  mammary 
neoplasms  are  malignant,  and  also  be  prevailed  upon  to  forget 
the  erroneous  teaching  of  a  past  era  relative  to  the  hopelessness 
of  mammary  carcinoma,  there  is  not  the  slightest  doubt  that  the 
percentage  of  radical  cures  by  operation  would  be  increased 
materially  during  the  next  few  years.  It  is  desirable,  as  Sir 
William  Banks  pointed  out  nearly  thirty  years  ago,  to  operate 
on  a  cancer  of  the  breast  when  it  is  no  larger  than  a  pea,  if 
patients  would  apply  to  us  at  that  time  or  if  diagnosis  could  be 
made.  Unfortunately  this  teaching  failed  to  fall  upon  fertile 
soil,  and  the  family  physician,  and  even  the  consulting  intern- 
ist, have  continued  to  distribute  that  death-dealing  advice 
"wait  and  see  if  it  is  malignant."  Worse  than  this  they  have 
complacently  continued  to  advise  against  operation  even  after 
the  malignant  nature  of  the  disease  has  manifested  itself  in 
unmistakable  signs,  in  the  meantime  repeatedly  plastering  the 
affected  breast  with  antiphlogistine,  ichthyol,  or  belladonna 
ointment. 

This  lack  of  faith  in  the  power  of  surgery  to  cure  is  not  so 
much  to  be  wondered  at  in  view  of  the  teachings  formerly  pro- 
mulgated by  many  surgeons  of  repute.  The  pity  is  that  the 
work  of  modern  investigators  and  operators  has  not  been  more 
closely  followed.  Rarely  a  month  passes  that  the  unfortunate 
experience  and  still  more  regrettable  teachings  of  a  late  illustri- 
ous professor  of  surgery  in  Philadelphia  are  not  quoted  to  me 
by  some  of  his  pupils.     It  seems  exceedingly  strange,  however, 


236  Diseases  of  the   Breast. 

that  the  more  advanced  and  better  teaching  of  an  equally  illus 
trious  contemporary  is  not  more  generally  remembered,  for  it  was 
through  him  that  the  complete  operation  and  teachings  of  Moore, 
of  London,  were  first  practised  and  inculcated  in  America. 

My  statistics  based  on  5,000  cases  show  that  in  any  given  case  of 
mammary  neoplasm  the  chances  are  more  than  5  to  1  in  favor 


Fig.  35. — Recurrent  carcinoma. 

of  malignancy.  If  conditions  were  reversed,  and  the  chances 
only  1  in  5  in  favor  of  malignancy,  the  dilly-dally  policy  so 
often  adopted  could  only  be  justified  on  the  ground  that  a  sur- 
gical operation  promising  relief  is  more  dangerous  to  life  than 
the  disease  itself.  But  such  is  not  the  case.  My  statistics 
based  on  2133  operations  performed  since  1893,  by  twenty-one 
American  surgeons,  show  the  operative  deaths  to  be  less  than  1 


Recurrent    carcinoma.     Observe    edema    of    the    arm.      Interscapulo- 
thoracic  amputation  was  performed. 


PLATE  XLI. 


Patient  shown  in  Plate  XL  after  interscapulo-thoracic  amputation 
had  been  performed. 


Carcinoma.  241 

percent.  In  view  of  the  fact  that  all  malignant  disease  untreated 
by  surgical  means  must  sooner  or  later  end  in  death,  this  slight 
mortality  following  operation  is  scarcely  to  be  considered. 
What  consistency,  I  ask,  is  there  in  advising  a  woman  with  a 
small  ovarian  cyst  or  myoma  of  the  uterus — neither  of  which 
has  a  tendency  per  se  to  shorten,  much  less  to  terminate  life— to 
travel  hundreds  of  miles  that  a  specialist  may  do  a  laparotomy, 
and  the  same  day,  perhaps,  admonish  her  sister  or  friend  with  a 
mammary  tumor  that  she  must  calmly  and  resignedly  await  a 
lingering,  painful  and  loathsome  death,  rather  than  submit  to  a 
less  dangerous  operation  curing  permanently  all  benign  growths 
and  at  least  one-third  of  the  malignant  ones? 

Certainly  none  whatsoever,  and  it  is  worse  than  folly  to  adopt 
such  a  course.  The  first  class  of  cases  are  operated  on  largely 
for  convenience,  such  as  relief  of  pain,  mental  anxiety,  deform- 
ity, and  possible  danger  to  life  by  accident.  They  should 
be  operated  by  all  means,  but  are,  as  I  have  said,  largely 
operations  of  election;  whereas  a  tumor  of  the  breast  being 
very  generally  malignant  should  demand  an  immediate  opera- 
tion to  save  life  itself.  The  fault  is,  in  part  at  least,  a  divided 
one,  falling  somewhat  upon  the  patient  as  well  as  the  doctor, 
owing  to  the  tendency,  already  mentioned  under  symptomat- 
ology, which  women  show  to  conceal  a  growth  in  the  breast. 

After  these  preliminary  considerations,  the  importance 
of  which  I  cannot  lay  too  much  stress  upon,  it  is  my  purpose  to 
explain  as  best  I  can  the  manner  in  which  mammary  carci- 
noma may  be  the  most  certainly  recognized,  and  to  contrast  its 
manifestations  with  those  of  other  diseases  of  the  breast  with 
which  it  may  be  confounded. 

The  article  on  symptomatology  has,  I  trust,  portrayed  the 
general  aspect  of  the  disease.  Here  I  shall  refer  to  and  elabor- 
ate those  symptoms  and  signs  which  are  the  most  distinctive. 

The  method  of  examining  a  patient  in  whom  a  mammary 

neoplasm  is  suspected  is  most  important.     It  is  always  neces- 
16 


242  Diseases  of  the   Breast. 

sary  to  have  the  patient  remove  all  clothing  covering  the  thorax, 
so  that  thorough  inspection  of  both  breasts  can  be  made  and 
any  asymmetry,  either  natural  or  acquired,  noted.  Most  of 
the  women  I  have  examined  have,  unless  otherwise  requested, 
merely  loosened  their  clothing  sufficiently  to  expose  the  affected 
breast.  It  is  my  custom  at  present  to  ask  them  at  once  to  pre- 
pare for  a  thorough  examination  of  the  entire  thoracic  region. 

This  enables  the  surgeon  to  examine  the  axillae,  the  supra- 
clavicular region,  and  the  opposite  breast,  as  well  as  the  one  of 
which  the  patient  complains;  and  also  to  detect  at  once  any  in- 
volvement of  the  integument  over  the  lateral  thoracic  walls  or 
epigastric  region. 

In  cases  much  advanced  the  thorax  should  be  carefully 
percussed  and  auscultated  for  evidences  of  pleurisy,  and  the 
liver  examined,  to  determine,  if  possible,  the  presence  of  cancer- 
ous nodules.  The  respirations  should  be  counted,  and  if  at 
all  increased  in  frequency,  inquiry  should  be  made  in  regard  to 
the  existence  of  dyspnea. 

All  portions  of  the  breast  should  be  examined,  the  tissues 
being  not  merely  picked  up  between  thumb  and  fingers,  but 
the  flat  of  the  four  fingers  being  passed  over  every  portion  of 
the  gland,  so  that  differences  in  hardness,  contour  and  mobility 
may  be  the  better  determined.  In  this  manner  the  firm,  in- 
durated, ill-defined  mass  characteristic  of  beginning  or  early 
carcinoma  may  be  accurately  made  out. 

In  fat  women  this  method  of  examination  will  not  yield 
satisfactory  results  as  readily  as  it  will  in  those  who  are  thin- 
ner. In  the  former  class  a  scirrhus  growth  of  considerable 
size  may  produce  simply  a  dimpling  or  puckering  of  the  skin 
over  it,  and  exceedingly  deep  palpation  with  thumb  and  fingers 
will  be  necessary  to  detect  any  induration  in  the  gland  itself. 

The  location  of  a  tumor  is  of  considerable  significance  from 
a  diagnostic  standpoint,  malignant  growths  being  most  common 
in  the  upper  and  outer  quadrant,  lower  or  axillary  quadrant,  and 


PLATE  XLII. 


Gl^ 


Sternal  symptom.     (Herbert  Snow.) 


Carcinoma.  245 

behind  the  nipple.  Benign  growths  on  the  contrary  are  most 
frequently  found  in  the  upper  and  inner  quadrant  or  sternal 
half  of  the  gland.  When  situated  beneath  the  nipple,  it  is  to  be 
remembered  that  they  produce  contraction  of  this  structure,  a 
phenomenon  which  is  an  important  diagnostic  sign.  Its  absence, 
however,  must  not  be  misconstrued  in  favor  of  benignity,  for 
the  sign  will  not  be  caused  by  tumors  remotely  situated  from 
the  nipple. 

The  location  of  the  neoplasm  is  also  of  some  importance  in 
regard  to  the  distribution  of  metastases.  Thus  a  tumor  in 
the  upper  hemisphere  is  more  likely  to  cause  early  involvement 
of  the  supraclavicular  glands,  while  one  in  the  inner  hem- 
isphere predisposes,  I  believe,  to  infection  of  the  mediastinal 
glands. 

The  sternal  symptom  of  Snow  has  already  been  alluded  to 
in  this  latter  connection.  It  will,  of  course,  be  present  only 
in  advanced  cases.  Indeed,  I  have  rarely  seen  it.  (See 
Plate  XLII.) 

In  regard  to  subjective  symptoms,  it. is  important  first  of  all 
to  bear  in  mind  that  the  onset,  as  a  rule,  is  not  marked  by 
any  suffering.  Contrary  to  the  popular  opinion  and  one,  too, 
which  I  am  sorry  to  state  still  continues  to  be  shared  by  many 
members  of  the  medical  profession,  mammary  carcinoma  may 
attain  a  well-advanced  degree  of  development  before  it  produces 
any  pain.  It  is  only  when  the  tumor  attains  considerable  size 
or  compresses  nerve-trunks — either  of  itself  or  through  its  as- 
sociated glandular  involvement — that  a  sense  of  heaviness  and 
weight  in  the  first  instance  and  of  lancinating  pains  radiating 
to  the  arm,  shoulder  and  back,  in  the  second,  will  be  experi- 
enced. Adhesion  of  the  tumor  to  the  skin  may  also  give  rise 
to  pain,  and  ulceration  naturally  causes  much  suffering. 

I  have  rarely  seen  a  case  in  which  the  slight  twinge  or  pang 
like  the  prick  of  a  needle  was  experienced  around  the  thorax  or 
down  the  arm  very  early  in  the  course  of  the  disease,  although 


246  Diseases  of  the   Breast. 

this  is  a  symptom  upon  which  Mr.  Sheild  places  considerable 
dependence.  The  late  S.  W.  Gross  also  believed  it  to  be  a 
valuable  sign. 

Pain  when  present  is  almost  always  of  a  neuralgic  or  inter- 
mittent character,  and  I  have  observed  in  many  cases  that  it  is 
much  worse  in  damp  weather.  Another  point  of  importance  is 
that  the  carcinomatous  breast  is  rarely  painful  to  manipulation. 

In  advanced  cases  associated  with  edema  of  the  upper  arm, 
there  is  also  much  pain  experienced,  but  the  associated  phe- 
nomena of  the  disease  when  it  has  reached  such  a  stage  are  so 
distinctive  as  to  render  the  trouble  in  the  arm  insignificant 
from  a  diagnostic  standpoint.  The  same  is  true  of  the  girdle 
pain  which  occurs  in  cancer  en  cuirasse.  In  the  comparatively 
rarer  forms  of  the  disease,  such  as  acute  cancer  and  cancer 
cysts,  the  symptoms  and  signs  are  likewise  so  pronounced  that 
they  overshadow  pain  and  tenderness,  which  at  best  are  insig- 
nificant in  any  form  of  the  disease  so  far  as  their  diagnostic 
value  is  concerned. 

It  is  timely  that  physicians  should  realize  this  fact  and 
more  frequently  combat  and  endeavor  to  dispel  the  erroneous 
idea  generally  entertained  by  women  that  because  a  growth 
is  painless  it  is  not  dangerous.  A  woman  often  remarks  to  me 
with  evident  surprise  that  she  can  hardly  believe  a  tumor  is 
cancerous  because  it  has  never  hurt  her,  and  this  despite  the 
fact  that  there  is  a  decided  tendency  among  women  to  regard 
all  tumors  in  the  breast  as  cancers. 

Age  is  without  doubt  one  of  the  most  valuable  guides,  as 
carcinoma  is  by  far  most  common  after  the  fortieth  year,  when 
the  functional  activity  of  the  breast  is  ceding  to  retrograde 
changes  or  when  such  changes  have  already  become  estab- 
lished. It  has  already  been  pointed  out  under  symptomatology, 
that  young  women  are  far  from  exempt,  and  therefore  the  pres- 
ence of  an  otherwise  suspicious  growth  in  the  breast  should  not 
lead  one  to  discard  the  opinion  that  it  may  be  carcinoma  merely 


Carcinoma.  247 

because  the  patient  happens  to  be  young  in  years.  My 
statistics,  based  upon  5,000  cases,  show  that  9  percent  occurred 
in  women  between  the  ages  of  twenty  and  thirty,  and  11.5 
percent  between  the  ages  of  thirty  and  forty.  These  figures 
certainly  show  the  folly  of  dismissing  from  consideration  the 
possibility  of  a  growth  being  malignant  merely  because  it  affects 
the  breast  of  a  young  woman.  It  is  true  that  the  majority 
of  hard  tumors  of  the  breast  occurring  in  women  under  thirty 
are  of  the  fibro-epithelial  group  of  benign  neoplasms,  but  still, 
in  view  of  the  considerable  percentage  of  carcinomata  oc- 
curring in  young  women,  the  possibility  of  a  tumor  being  car- 
cinomatous must  be  reckoned  with. 

In  doubtful  cases  of  this  kind,  and  also  particularly  in  cases 
where  it  is  difficult  to  differentiate  between  carcinoma  and 
chronic  mastitis  (abnormal  involution),  the  microscopic  test 
is  a  most  valuable  means  of  diagnosis.  Instead  of  making, 
as  many  advise,  an  incision  into  the  growth  for  diagnostic  pur- 
poses, and  then  closing  the  wound — a  practice  not  altogether 
satisfactory,  and  certainly  not  free  from  danger — I  prepare  for 
and  get  the  consent  of  the  patient  for  a  complete  operation. 

A  competent  microscopist  is  present  with  his  apparatus, 
prepared  for  rapid  yet  accurate  work.  If  the  chances  strongly 
favor  benignity,  the  tumor  and  its  capsule  only  are  removed 
and  submitted  for  an  immediate  examination  and  opinion. 

Usually  in  less  than  ten  minutes  the  report  is  returned.  If 
there  is  a  strong  suspicion  of  malignancy,  a  portion  of  the 
growth  near  the  center  is  removed,  the  wound  at  once  plugged 
with  gauze  and  nothing  further  done  until  the  pathologist  re- 
ports. If  the  piece  thus  removed  proves  malignant,  the  com- 
plete operation  is  immediately  performed.  I  have  followed  this 
practice  for  fourteen  years  and  have  never  known  a  mistake  to 
be  made  in  diagnosis,  nor  have  been  made  to  suspect  that  harm 
had  resulted  from  the  liberation  of  cancer  cells  which  affected 
adjacent  healthy  tissue.     I  think,  however,  that  the  wound 


248  Diseases  of  the   Breast. 

thus  treated  should  be  left  entirely  alone  until  the  breast  and 
the  muscles  have  been  removed.  Therefore,  it  would  seem 
that  the  danger  can  be  minimized  if  not  actually  prevented, 
and  the  slight  risk  incurred  is  as  nothing  to  the  definite  infor- 
mation gained.  I  can  point  to  women,  happily  married  and 
with  practically  perfect  breasts,  where  everything  might  have, 
probably  would  have,  been  different  had  not  this  precaution 
been  taken  in  operations  for  benign  growths  before  marriage. 
Further,  I  have  been  prevented  from  mistakes  in  at  least  six 
malignant  tumors. 

When  operating  apart  from  a  well-appointed  hospital  and 
its  pathologist,  the  macroscopic  appearance  of  the  tumor,  its 
color,  consistence,  resistance  to  the  knife,  and,  above  all,  the 
presence  or  absence  of  a  capsule,  will  as  a  rule  prevent  a  mis- 
take in  diagnosis.  Stiles's  nitric-acid  test  may  be  applied  to 
the  tumor  with  advantage.  Every  growth  removed  from  the 
mammary  gland  should,  of  course,  be  examined  with  the  mi- 
croscope as  soon  as  practicable. 

The  history  of  trauma,  mastitis,  and  discharge  from  the 
nipple  is  of  little,  if  any,  value,  as  it  is  about  as  commonly 
obtained  in  benign  growths  as  in  malignant  ones.  The  same 
is  true  in  regard  to  the  social  condition  of  the  patient,  for  the 
reason  that  carcinoma  is  frequent  enough  in  women  who  have 
never  borne  children  to  render  the  diagnostic  value  of  a  history 
of  parturition  and  lactation  relatively  unimportant.  In  any 
large  series  of  cases  there  is  found  a  certain  percentage  in  which 
these  etiological  factors  can  be  excluded. 

It  is  the  same  in  regard  to  heredity.  Although  I  believe 
a  peculiar  predisposition  to  carcinoma  may  be  inherited,  the 
absence  of  a  history  in  parents,  grandparents  or  other  relatives 
should  not  be  taken  into  account  when  there  are  good  reasons 
for  thinking  a  tumor  is  malignant.  A  positive  family  history  is 
of  course  to  be  regarded  as  strengthening  the  probability  of 
malignancy.     A  negative  history,  however,  does  not  weaken 


Carcinoma.  249 

the  likelihood  of  malignancy,  provided  that  other  circumstances 
point  to  it. 

In  regard  to  differential  diagnosis,  the  principal  conditions 
from  which  carcinoma  is  to  be  distinguished  are  benign 
tumors,  chronic  mastitis  or  abnormal  involution,  tubercu- 
losis, sarcoma,  and  cysts. 

The  tumors  of  the  fibro-epithelial  group,  with  the  exception 
of  the  papillary  cystadenoma,  will  as  a  rule  present  no  diffi- 
culties of  diagnosis.  Their  usual  location  in  the  sternal  half 
of  the  gland,  their  distinct  encapsulation,  the  absence  of  axillary 
involvement,  their  slow  growth  and  their  usual  occurrence  in 
young  women  render  their  recognition  easy,  as  a  rule.  When- 
ever doubt  exists  the  microscopic  method  above  described 
should  be  employed.  The  papillary  cystadenoma  is  hardly 
likely  to  be  mistaken  for  carcinoma,  although  it  may  undergo 
carcinomatous  degeneration  in  its  later  stages.  Macroscopic- 
ally  it  resembles  sarcoma  rather  than  carcinoma. 

Differential  diagnosis  from  chronic  mastitis  or  abnormal 
involution  may  be  impossible  without  the  aid  of  the  microscope. 
In  those  cases  in  which  the  chronic  inflammatory  process  per- 
sists as  a  relic  of  acute  disease  the  liability  to  confusion  with 
carcinoma  is  not  so  great  as  it  is  in  those  in  which  the  disease 
more  truly  represents  an  abnormal  process  of  involution.  Some 
cases  also  develop  rapidly  with  pain  and  swelling,  and  naturally 
would  not  be  mistaken  for  any  of  the  ordinary  forms  of  carci- 
noma. From  acute  cancer  they  differ  in  that  marked  glandu- 
lar involvement,  rapid  progression  to  ulceration,  and  profound 
constitutional  disturbances  are  absent. 

In  nearly  all  cases  of  abnormal  involution  pain  of  varying 
degree  is  a  prominent  symptom.  This  pain,  too,  is  frequently 
worse  at  the  menstrual  period.  Thus  a  condition  rarely 
if  ever  present  in  early  carcinoma  is  very  constant  in  chronic 
mastitis.  It  is  those  cases  in  which  pain  is  absent  that  are 
most  difficult  to  distinguish  from  beginning  cancer. 


2>Q 


Diseases  of  the   Breast. 


In  the  discrete  form  of  tuberculosis  areas  of  induration  will 
be  found  in  various  parts  of  the  breast,  and  in  some  cases  they 
can  be  distinctly  separated  from  the  surrounding  tissues.  This 
condition  is  never  found  in  carcinoma.  In  both  varieties  of 
tuberculosis — the  discrete  and  the  confluent — the  earlier  involve- 
ment of  the  axillary  lymphatic  glands,  their  more  rapid  growth, 
and  the  not  uncommon  development  of  suppuration  will  afford 
a  valuable  differential  diagnostic  sign.  Later  in  the  course 
of  the  disease  fistulae,  through  which  the  contents  of  tuberculous 
abscesses  are  discharged,  may  be  found  over  various  portions 
of  the  breast.  In  advanced  carcinoma  ulcerations  rather  than 
fistulas  communicating  with  the  parenchyma  of  the  gland  are 
present. 

Finally,  it  is  to  be  remembered  that  in  mammary  tuberculosis, 
the  lesions  can  often  be  demonstrated  in  other  organs  of  the 
body. 

Syphilis  should  not  present  difficulties  of  diagnosis  when  ap- 
pearing as  a  primary  lesion  or  as  gummata,  although  the  latter 
have  sometimes  been  mistaken  for  malignant  neoplasms.  As 
a  rule  evidences  of  syphilis  will  be  found  in  other  parts  of  the 
body.  Gummata  have  a  marked  tendency  to  soften  if  left  un- 
treated, and  as  this  softening  develops  it  imparts  an  elastic 
feeling  to  the  mass  upon  palpation.  When  softening  has  pro- 
gressed to  such  an  extent  as  to  cause  breaking  down  of  the  mass, 
the  resulting  ulcer  is  decidedly  excavated  and  'sharply  defined 
in  contradistinction  to  the  more  irregular  ulceration  of  car- 
cinoma. Even  after  a  gumma  has  sloughed  there  may  be 
practically  no  involvement  of  the  axillary  lymph-nodes.  An- 
other difference  between  gumma  and  carcinoma  is  that  the 
former  may  attain  a  large  size  before  becoming  adherent  to 
the  skin.  In  such  cases,  however,  the  skin  will  often  be  found 
slightly  discolored. 

The  diffuse  form  of  syphilis,  which  resembles  chronic  mas- 
titis, may,  like  that  affection,  be  mistaken  for  scirrhus,  and  in  ab- 


Carcinoma.  251 

sence  of  history  or  evidence  of  syphilis  be  quite  impossible  to 
diagnosticate.  The  microscope  may  be  required  to  prove  that 
the  disease  is  not  carcinoma,  and  even  then  its  true  nature 
may  fail  to  be  revealed,  as  there  is  nothing  characteristic  of 
this  form  of  fibrosis. 

Finally,  it  must  be  borne  in  mind  that  large  doses  of  the  io- 
dides cause  a  rapid  change  for  the  better  in  late  syphilis  of  the 
breast  as  in  like  lesions  of  other  organs.  Cases  have  been 
reported  in  which  large  gummata  almost  completely  disappeared 
within  a  week  after  the  use  of  this  remedy  was  begun.  In  sus- 
picious cases  this  therapeutic  test  should  always  be  tried. 

To  the  experienced  surgeon  sarcoma  will  present  few  diffi- 
culties of  diagnosis  from  carcinoma,  and  even  to  those  who  see 
but  comparatively  few  cases  of  mammary  disease  differentiation 
should  not  be  difficult.  Their  possible  encapsulation,  their  rapid 
growth,  and  the  circumstances  that  they  do  not  become  adher- 
ent to  the  skin  or  retromammary  tissues  constitute  important 
diagnostic  differences.  Involvement  of  the  lymphatic  glands 
in  the  axilla  is  also  rare  in  sarcoma  and  constant  in  carcinoma. 
When  it  does  occur  in  the  former  the  glands  do  not  present  that 
fused,  matted  characteristic  which  is  invariable  in  the  latter. 
When  sarcoma  becomes  large  the  veins  in  the  overlying  skin 
become  much  distended,  and  thus  furnish  a  sign  which  is  not 
present  in  carcinoma.  Finally,  when  the  stage  of  ulceration  is 
reached  the  protrusion  of  fungous  sarcomatous  masses  will 
make  the  nature  of  the  disease  apparent.  It  has  always  been 
customary  to  state  that  sarcomata  occur  most  frequently  in 
women  who  have  not  reached  middle  life,  and  to  consider  their 
supposed  predilection  for  those  young  in  years  as  a  diagnostic 
sign  of  value.  My  statistics,  however,  show  that  more  cases 
occur  in  elderly  than  in  young  women.  Hence  it  would  seem 
that  age  incidence  is  not  so  important  as  it  has  been  considered 
to  be. 

Cysts  have  frequently  been  mistaken  for  carcinoma  and 


252  Diseases  of  the   Breast. 

their  true  nature  revealed  only  at  the  time  of  operation. 
Although  cysts  of  any  material  size  usually  impart  a  sensation 
of  elasticity  to  the  palpating  fingers,  there  is  a  small  percentage 
in  which  this  attribute  is  wanting,  as  a  result  of  which  they 
have  been  erroneously  thought  to  be  cancers,  particularly 
in  those  cases  in  which  they  have  occurred  in  the  breasts  of 
elderly  women.  The  circumstance  that  suppuration  of  the 
cyst  contents  has  led  to  some  enlargement  of  the  axillary  nodes 
in  many  of  these  cases  has  strengthened  the  supposition  that 
this  disease  was  carcinomatous.  Of  course,  in  those  cases 
in  which  the  suspicion  of  a  cyst  is  present,  aspiration  will  set- 
tle the  question. 

The  involution  cysts  are  the  ones  which  give  rise  to  most 
difficulty,  and  as  they  may  terminate  in  carcinomatous  degen- 
eration their  recognition  becomes  the  more  important. 

I  am  of  the  opinion  that  in  the  majority  of  these  cases  the 
microscope  will  be  required  to  differentiate  between  simple 
abnormal  involution,  involution  cysts,  and  beginning  carcinoma. 

The  more  serious  of  these  conditions  cannot  be  separated 
clinically  from  simple  abnormal  involution,  and  the  small  cysts 
are  so  compressed  by  the  fibrous  tissue  in  the  breast  that  they 
may  readily  escape  detection  until  the  knife  has  laid  them  bare. 
Several  portions  of  the  gland  should  always  be  turned  over  to 
the  pathologist,  so  that  a  thorough  examination  can  be  made. 

Under  the  microscope  differences  are  seen  which  cannot  be 
detected  macroscopically.  Thus  it  can  be  learned  whether 
the  epithelium  is  proliferating,  whether  minute  papillary  out- 
growths from  the  cyst- wall  are  present,  or  whether  the  cysts 
represent  merely  a  dilatation  of  the  ducts  and  acini.  Cancerous 
change  can,  of  course,  be  detected  in  this  manner  when  it  is 
present. 

Adenocarcinoma  is  to  be  differentiated  from  the  adenomata 
by  its  tendency  to  infiltrate,  its  larger  size,  its  constant,  steady 
growth  which  finally  terminates  in  ulceration,  and  microscop- 


Carcinoma.  253 

ically  by  the  atypical  formation  of  the  acini,  combined  with  the 
great  thickness  of  the  walls  and  the  breaking  of  the  epithelium 
through  the  basement  membrane. 

Prognosis. — Untreated,  cancer  of  the  breast  will  almost 
invariably  result  in  the  destruction  of  the  patient  within  three 
years.  The  percentage  of  patients  living  after  this  time  is  so 
small  that  it  may  practically  be  disregarded.  That  the  disease 
is  strictly  local  in  its  beginning,  and  therefore  amenable  to 
early  and  radical  surgical  treatment,  is  a  fact  which  I  wish  most 
strongly  to  emphasize. 

At  the  present  day  it  hardly  need  be  said  that  the  earlier 
the  operation  can  be  performed  the  greater  are  the  chances  of 
recovery.  This  fact  was  well  attested  by  the  statistics  of  some 
of  the  older  surgeons  whose  observations  were  recorded  before 
the  more  thorough  methods  of  operating  had  come  into  vogue. 
Thus,  Winniwarter  found  the  average  duration  of  life  after 
operation,  in  cases  in  which  the  operation  was  done  before 
gross  involvement  of  the  axillary  or  supraclavicular  glands  had 
occurred,  to  be  22  months;  whereas  in  those  in  which  such 
glandular  involvement  had  taken  place  it  was  only  13  months. 
Naturally  much  depends  upon  the  thoroughness  with  wThich  the 
diseased  structures  are  removed.  It  is  most  gratifying  to  note 
the  greater  percentage  of  patients  who  remain  free  at  the  end 
of  three  years  since  the  extensive  operative  methods  practised 
by  Halsted,  Meyer,  Rotter,  Stiles,  Warren,  Lennander,  myself 
and  others  have  come  to  be  more  generally  employed.  Although 
the  results  obtained  by  different  operators  show  considerable 
variation,  the  highest  percentage  of  cases  remaining  free  from 
recurrence  at  the  end  of  three  years  is  attained  by  those  surgeons 
who  do  the  complete  operation.  This  is  a  percentage  varying 
from  40  to  50,  and  should  serve  as  a  conclusive  argument  in 
favor  of  the  extensive  removal  of  all  accessible  tissue  which 
can  possibly  be  diseased. 

This   estimate  coincides  with  the  statistics   of  Mantra  ff. 


254  Diseases  of  the   Breast. 

compiled  independently  of  any  material  upon  which  I  based 
my  opinion.  In  his  Wurzburg  dissertation,  1904,  he  analyzed 
860  cases  and  found  that  recurrence  took  place  in  430.  The 
longest  period  of  immunity  in  these  cases  was  11  years. 

Other  series  of  cases,  however,  do  not  show  such  favorable 
results,  the  percentage  of  freedom  from  recurrence  at  the  end 
of  three  years  varying  from  20  to  30.  Some  of  these  series  of 
cases  have  been  compiled  from  the  operations  of  many  different 
surgeons,  and  it  is  only  fair  to  assume  that  the  methods  of 
operating  and  the  selection  of  cases  for  complete  operation 
have  varied  sufficiently  to  account  for  the  differences  in  the 
ultimate  result  of  operation.  I  still  maintain  that  surgery 
should  cure  one-half  of  all  cases  provided  that  they  can 
be  subjected  to  the  complete  operation  early  in  the  course 
of  the  disease. 

In  a  series  of  twenty-one  private  cases,  all  that  I  had  between 
the  years  1898  and  1904,  and  every  one  of  which  has  been 
followed  accurately  up  to  July  1,  1907,  fourteen  patients,  or 
66f  percent,  remain  free  from  any  sign  of  recurrence  whatso- 
ever, either  regional  or  internal.  That  I  am  prepared  to  expect 
recurrences  in  some  of  these  goes  without  saying.  Realizing 
fully,  however,  the  extent  of  the  operation  done  in  each  case, 
I  shall  be  much  surprised  if  more  than  one  or  two  develop 
trouble.  Since  1904  I  have  operated  on  a  much  larger  number 
of  patients  who  have  gone  a  year,  a  year  and  a  half,  two  years, 
and  two  years  and  a  half,  without  recurrence,  but  of  course 
they  cannot  be  included  in  the  series.  I  may  state  here,  how- 
ever, that  I  have  never  encountered  among  my  own  patients 
any  case  recurring  after  two  years  and  seven  months. 

I  have  made  no  effort  to  include  any  of  my  hospital  cases, 
as  it  is  impossible  to  follow  them  in  all  instances  and  is 
manifestly  unfair  to  include  a  portion  of  them  known  to  have 
been  favorable. 

Naturally  those  cases  in  which  the  axillary  glands  are  grossly 


Carcinoma.  255 

diseased,  in  which  the  tumor  is  firmly  adherent  to  the  skin, 
and  in  which  ulceration  has  occurred,  offer  a  less  favorable 
prognosis  than  those  in  which  these  phenomena  are  not  present. 
Those  in  which  ulceration  has  taken  place  are  the  most  unfavor- 
able of  all.  Of  thirty-one  patients  operated  upon  after  ulcera- 
tion had  taken  place  Wunderli  reports  only  two  living  at  the 
end  of  three  years.  Cases  in  which  the  supraclavicular  glands 
are  involved  also  offer  a  poor  prognosis,  but  I  do  not  consider 
them  inoperable  unless  the  glands  in  the  higher  triangles  of  the 
neck  are  affected.  Although  I  cannot  state  that  I  have  ever 
cured  a  patient  who  had  neck  involvement,  I  had  one  who  went 
four  years  without  recurrence  above  the  clavicle  even  though 
recurrence  took  place  in  the  breast  incision  within  three  years. 
I  therefore  believe  that  life  may  be  prolonged  and  rendered 
tolerable  by  operating  upon  patients  who  have  involvement 
of  the  lower  cervical  glands. 

A  question  of  importance  relative  to  the  prognosis  in  cases 
which  have  been  subjected  to  operation  is,  "when  may  a  pa- 
tient be  considered  to  have  passed  the  danger  of  recur- 
rence?" While  all  recognize  that  Volkmann's  three-year 
limit  is  too  short  and  should  be  extended  to  at  least  five 
years,  it  is  nevertheless  a  fair  working  rule,  inasmuch  as  80 
or  85  percent  of  all  patients  who  pass  this  limit  remain  free 
from  subsequent  trouble.  After  five  years  probably  less  than 
10  percent  of  all  cases  show  recurrence.  Of  twenty  recur- 
rences analyzed  by  Marggraff  twelve  took  place  during  the 
third  and  fourth  years  and  four  during  the  fifth  and  sixth 
years.  These  figures  are  very  significant.  A  five  year  limit 
is  of  course  far  from  being  absolutely  protective,  but  a  limit 
which  is  so  cannot  be  set,  inasmuch  as  recurrences  have  been 
known  to  take  place  after  ten,  fifteen,  twenty  and  even  twenty- 
five  years. 

The  subject  of  late  recurrence  has  recently  been  investigated 
by  Ransohoff,  of  Cincinnati.     He  collected  thirty-seven  cases 


256  Diseases  of  the   Breast. 

in  which  recurrence  took  place  after  seven  or  more  years.  Of 
these  twenty-six  were  clearly  local,  and  eleven  were  doubtful. 
Warren,  Carson,  Bevan  and  Senn  have  each  had  a  case  after 
eight  years.  Shepherd  has  had  one  after  nine  and  eleven 
years  respectively;  Moore  and  Vanderveer  each  one  after 
twelve  years;  McLaren  one  after  thirteen  years;  Armstrong 
and  Bloodgood  each  one  after  fifteen  years;  Coley  one  after 
seventeen  years;  Ransohoff  one  after  twenty  years;  Deaver 
one  after  twenty  years;  Matas  one  after  twenty-five  years. 
Ransohoff  states  that  he  was  unable  to  find  any  case  in  literature 
in  which  the  interval  between  the  time  of  operation  and  the 
recurrence  of  the  disease  was  as  long  as  twenty  years.  The 
cases  of  Deaver  and  Matas  were  reported  to  him  in  personal 
communications.  (See  Ransohoff's  paper  in  Transactions  0} 
the  American  Surgical  Association,  1907.) 

My  belief  is  that  nearly  all  such  reported  late  recurrences 
are  really  not  recurrences  at  all,  but  fresh  outbreaks  in  subjects 
with  a  demonstrated  susceptibility  to  the  disease.  This  I 
believe  to  be  particularly  true  in  regard  to  recurrence  in  the  vis- 
cera and  bones.  It  is  difficult  to  understand  how  cancer-cells 
could  lie  dormant  in  internal  organs  for  so  many  years  without 
giving  trouble.  Certainly  internal  cancer  affecting  such  organs 
as  the  stomach  and  rectum,  for  instance,  where  there  is  no 
direct  lymphatic  connection  with  the  mammary  gland,  can 
be  better  understood  and  explained  on  the  theory  of  a  fresh 
outbreak  than  by  supposing  them  to  be  directly  the  result  of  a 
carcinoma  of  the  breast  antedating  them  by  a  decade  or  longer. 

Do  we  believe  that  cancer  of  the  liver,  stomach,  uterus  and 
other  internal  organs  runs  such  a  quiescent  course  that  patients 
live  without  symptoms  for  many  years?  By  no  means!  And 
yet  we  must  suppose  that  such  is  the  case  if  they  are  secondary 
growths  following  a  primary  focus  in  the  breast  which  was  re- 
moved years  before,  and  which  itself  has  shown  no  signs  of  re- 
curring:. 


Carcinoma.  257 

If  local  recurrence  takes  place,  then  it  is  presumable  that 
cancer-cells  were  left  behind  at  the  time  of  operation.  But 
even  in  such  cases  is  it  not  conceivable  that  we  may  have 
malignant  degeneration  in  a  cicatrix,  which  we  know  is  prone 
to  occur  in  other  parts  of  the  body  in  non-carcinomatous  pa- 
tients ?  Much  more  likely  is  it  to  occur  in  those  with  known 
predisposition  to  the  disease. 

Of  all  the  factors  influencing  prognosis  the  variety  of  the 
neoplasm  is  the  most  important.  Medullary  carcinoma  is 
the  most  malignant,  adenocarcinoma  the  least.  Scirrhus  occu- 
pies an  intermediate  position,  and,  as  already  stated,  withering 
or  atrophic  scirrhus  is  less  virulent  than  the  ordinary  form. 
The  rapidly  fatal  course  of  acute  cancer  has  also  been  alluded 
to,  and  the  hopelessness  of  cancer  en  cuirasse  set  forth. 

As  regards  age,  I  believe  that  mammary  carcinoma  pursues 
a  more  fatal  course  in  young  persons  than  in  old,  for  the  reason 
that  in  the  former  class  the  lymphatics  are  both  more  numer- 
ous and  more  patent. 

Concerning  operative  mortality,  my  statistics  collected  three 
years  ago  are  significant.  These  statistics,  based  on  2133 
operations,  performed  between  the  years  1893  and  1903,  by 
twenty-one  American  surgeons,  show  the  death  rate  to  be 
less  than  one  percent.  This  seems  almost  incredible  when 
contrasted  with  the  fifteen  to  twenty-five  percent  mortality 
following  incomplete  operations  in  pre-antiseptic  days. 

[Since  the  above  went  to  the  printer,  Halsted's  most  recent 
article*  has  appeared.  It  particularly  emphasizes  the  desira- 
bility of  operating  before  axillary  or  other  lymphatic  involve- 
ment. Of  64  such  cases  operated,  80  percent  were  free  from 
recurrence  and  apparently  well  at  the  end  of  three  years.  It 
is  true  that  many  of  these  cases  were  adenocarcinomata,  in 
which  there  is  little  tendency  to  lymphatic  involvement. 
Therefore,    early  operation   should   be   insisted   upon,   for  if 

*Annals  of  Surgery,  July,  1907. 
17 


258  Diseases  of  the   Breast. 

done  before  axillary  involvement,   four  out  of  five   may   be 
cured. 

Halsted 's  statistics  also  show  that  where  there  was  involve- 
ment of  the  axillary  glands,  there  were  only  24.5  percent  of 
cures;  so  with  axillary  involvement  the  chances  of  cure  are 
about  one  in  four,  without  axillary  involvement,  four  in  five. 
No  stronger  argument  could  be  made  for  prompt  interference 
in  any  suspicious  growth  of  the  breast. 

It  also  appears  from  this  publication  that  in  at  least  two 
instances  Halsted  encountered  decided  axillary  involvement 
when  the  primary  focus  in  the  breast  was  so  obscure  as  to 
escape  notice. 

Halsted  still  insists  upon  the  neck  operation,  doing  it  in  119 
cases  of  the  232  reported.  In  44  patients  the  glands  of  the 
neck  as  well  as  those  of  the  axilla  were  involved.  "Three  of 
these  (or  7  percent)  were,  it  seems,  definitely  cured." 

It  will,  therefore,  be  seen  that  the  statistics  of  the  Johns 
Hopkins  Hospital  (232  cases  covering  a  period  of  more  than 
15  years)  indicate  that  27  percent  of  the  patients  at  the  time  of 
operation  were  free  from  axillary  involvement.  Halsted  himself 
evidently  thinks  that  this  showing  is  too  favorable,  as  he  says 
very  properly:  "  We  must  bear  in  mind,  however,  that  surely 
in  some  and  probably  in  many,  if  not  in  most  of  the  axillae 
recorded  as  negative,  there  was  disease." 

In  my  own  series  of  21  private  patients  where  this  feature 
was  carefully  noted  and  recorded,  but  two  of  them,  one  of 
adenocarcinoma  and  one  of  scirrhus,  showed  negative  axilke 
at  the  time  of  operation.  It  is  my  invariable  custom  to  submit 
all  axillary  tissues  removed  to  the  microscopist  and  never  to 
wholly  depend  upon  macroscopic  appearances. 

It  is  evident,  that  my  cases  were  at  least  of  average,  if  not 
more  than  average,  severity.  One  of  them  had  been  operated 
upon  twice  before  by  other  surgeons  for  an  infiltrating  scirrhus; 
at  the  time  I  operated  there  was  little  hope  for  a  radical  cure, 


Carcinoma.  259 

although  I  did  a  very  extensive  operation  and  almost  lost  the 
patient  from  shock.     She  has  now  been  well  ten  years.] 

Treatment.' — There  is  but  one  treatment  for  cancer  of  the 
breast — operation — and  the  earlier  and  more  radical  it  is, 
the  better.  It  should  be  a  work  of  supererogation,  at  this 
time  to  insist  upon  the  fact  that  operation,  and  it  only,  is  of  the 
least  avail  in  this  frequent  and  distressing  malady.  In  dealing 
with  cancer  pessimism  is  so  easy,  optimism  so  difficult,  that  we 
can  hardly  expect  any  but  the  younger  medical  men  to  diagnos- 
ticate and  refer  their  cases  for  early  operation.  The  false 
teaching  of  a  past  era  still  abides  with  many  of  the  older  practi- 
tioners, and  they  can  neither  make  an  early  diagnosis  nor  ap- 
preciate the  necessity  of  sending  their  cases  to  some  one  who  can. 

The  internist  should  definitely  refuse  to  treat  neoplasms  of 
the  mammary  gland,  for  all  of  them  are  strictly  surgical;  they 
are  generally  malignant,  and,  therefore,  amenable  only  to 
operative  procedures. 

He  has  learned,  or  is  fast  learning,  his  lesson  in  appendicitis, 
strangulated  hernia,  and  other  such  acute  affections  having 
a  rapid  and  tragic  end  without  surgical  intervention;  but  in 
gall  stones  we  still  hear  much  of  olive  oil  and  in  gastric  ulcer  too 
much  about  diet  and  drugs,  which,  valuable  as  they  are, 
frequently  are  persisted  in  until  either  hemorrhage  or  perfora- 
tion rings  in  the  last  scene  to  the  drama.  But  in  cancer  of  the 
breast,  stomach,  and  other  organs  where  there  is  absolutely 
no  excuse  for  delay,  and  where  the  course  of  the  disease  is 
relentless  and  certain,  the  same  responsibility  is  not  felt  on 
account  of  the  chronic  nature  of  the  disease.  It  is,  however, 
undoubtedly  a  far  greater  responsibility,  for  in  acute  disease 
nature  may  bring  amelioration,  if  not  relief;  whereas  in  cancer 
the  neglect  of  the  family  physician,  who  first  sees  the  case,  may 
condemn  his  patient  to  the  most  painful,  lingering,  and  loath- 
some of  deaths. 

The  law  holds  a  practitioner  responsible  for  failure  to  report 


260  Diseases  of  the   Breast. 

certain  infectious  diseases,  as  the  welfare  of  the  public  requires 
correct  and  prompt  action  on  the  part  of  medical  men.  That 
we  are  nearing  the  time  when  probably  the  law,  but  certainly 
public  sentiment,  will  hold  one  responsible  for  a  failure  to 
give  the  proper  advice  to  patients  with  cancer,  there  can  be 
little  doubt.  It  is,  in  my  judgment,  no  longer  justifiable  to 
deceive  patients  as  to  the  nature  of  their  disease,  for,  by  so 
doing,  they  are  lulled  into  a  false  security  and  prevented  from 
doing  that  which  they  are  nearly  always  willing  to  do  when  the 
matter  is  properly  and  intelligently  put  before  them.  Rarely 
have  I  had  a  woman  decline  interference  for  cancer  of  the 
breast  when  the  risk  of  the  operation  and  the  hazards  of  delay 
were  fairly  and  relatively  set  forth.  As  long  as  cancer  was 
synonymous  with  death,  a  want  of  candor  was  pardonable, 
perhaps  humane;  but  now  that  early  operation  rightly  done 
will  cure  at  least  one-third,  probably  one-half,  of  mammary 
carcinomata,  patients  and  their  friends  should  be  plainly  told 
the  truth,  delicately  and  with  consideration,  of  course,  but 
the  truth  nevertheless. 

The  public  understands  fairly  well  the  possibilities  of  surgery 
in  certain  diseases  and  it  is  not  to  be  questioned  that  it  will 
look  for  and  discover  those  who  have,  and  whose  results  give 
them  a  right  to  have,  a  reasonable  amount  of  optimism  in  the 
surgery  of  malignant  disease. 

I  count  myself  fortunate,  along  with  many  others,  to  have 
had  the  privilege  of  listening  to  the  teachings  and  to  have 
followed  as  house  surgeon  in  the  wards  and  operating  room  of 
Jefferson  Hospital,  that  brainy,  aggressive,  and  prescient  sur- 
geon, Samuel  W.  Gross,  who  was  curing  a  definite,  though  a 
small  percentage  of  mammary  carcinomata  at  a  time  when 
others  looked  upon  operation  as  little  short  of  leading  a  forlorn 
hope,  and  spoke  of  this  Apostle  of  a  new  faith  as  a  misguided 
optimist.  An  equally  illustrious  surgeon  and  teacher  in  this 
city  was,  at  the  same  time,  declaring  that  he  had  removed  a 


Carcinoma.  261 

"cart  load  of  breasts  for  cancer  and  had  not  obtained^a  single 
cure."  The  teaching  of  these  two  men  is  felt  in  Philadelphia 
to-day,  and  is  in  a  measure  exemplified  in  the  practice  of  their 
respective  pupils,  though  a  generation  has  passed.  The  one 
greatly  advanced  the  cause  of  surgery  of  the  breast,  the  other 
as  much  retarded  it. 

Latterly  it  has  become  somewhat  the  custom  with  practi- 
tioners to  recommend  a  course  of  X-ray  treatment  before 
operation.  The  practice  cannot  be  too  pointedly  condemned 
inasmuch  as  it  has  been  productive  of  little,  if  any,  good  even 
in  a  minority  of  cases,  and  in  all  wastes  valuable  time — possibly 
allowing  internal  metastases  to  occur  before  operation  is 
instituted.  I  regard  the  practice  of  using  X-rays,  or  other 
local  treatment  before  operation,  as  always  injudicious,  often 
positively  injurious  and,  therefore,  highly  censurable.  I 
shall  later  speak  of  this  remedy  as  supplementary  to  operation 
and  in  the  treatment  of  inoperable  growths. 

Before  any  operation  in  mammary  cancer,  we  should  always, 
so  far  as  possible,  eliminate  the  probability  of  internal  metas- 
tasis. The  liver,  the  lungs,  and  bones  should  be  carefully 
interrogated,  as  these  organs  are  most  often  the  sites  of  secon- 
dary foci.  That  it  will  be  clearly  impossible  to  recognize 
beginning  infection  in  any  of  these  is,  unfortunately,  true; 
but  gross  or  palpable  invasion  should  prevent  an  operation 
for  the  removal  of  the  primary  focus  unless  it  be  undertaken 
simply  as  a  palliative  procedure  and  with  no  hope  of  a  radical 
cure.  Such  operations  do  but  little  good  and  discredit  both 
the  operator  and  surgery. 

One  has  only  to  follow  the  operation  for  cancer  of  the  breast 
through  its  various  evolutionary  stages,  to  be  convinced  that 
the  radical  procedure,  as  we  now  understand  it,  is  as  much 
better  than  the  partial  operations  practised  before  Halsted's 
epoch-making  paper  in  the  Annals  of  Surgery  in  1894,  as  these 
were  better  than  the  caustics,  electricitv  and  internal  medica 


262  Diseases  of  the  Breast. 

tion  of  former  days.  The  argument  often  made  that  extensive 
operations_  are  not  justifiable  in  cases  seen  early  is  entirely 
erroneous.  Truth  to  say,  early  cases  are  the  very  ones  where  a 
complete  operation  should  be  done,  as  there  is  for  them  a  sub- 
stantial hope  of  a  permanent  cure.  Moreover,  it  is  impossible 
to  determine  by  any  examination,  however  carefully  conducted, 
the  exact  limits  of  a  growth  that  is  always  unencapsuled  and 
infiltrating  in  its  nature,  such  as  cancer.  Therefore,  it  is 
always  safe  to  assume  that  there  is  a  more  extensive  zone  of 
infection  than  is  apparent,  and  that  it  is  wise  to  remove  enough 
tissue  to  insure  its  probable  complete  eradication,  inasmuch 
as  this  can  be  done  without  increasing  the  operative  mortality 
or  lessening  the  future  usefulness  of  the  patient.  To  do  this 
one  must  constantly  keep  in  mind  the  fact  that  carcinoma 
generalizes  through  the  lymphatics,  and  that  early,  very  early, 
in  the  disease  the  axillary  lymphatic  glands  become  involved, 
so  that  in  any  operative  procedure  the  primary  focus  in  the 
breast,  the  axillary  nodes,  and  the  intervening  lymph-bearing 
vessels  containing  cancer  cells  must  be  simultaneously  removed. 
Hence  the  utter  inadequacy  of  treatment  by  caustics,  which 
at  the  most  can  only  reach  the  primary  focus  in  the  breast,  and 
can  only  do  this  in  small,  discrete  growths  at  the  expense  of 
great  pain,  sloughing,  and  probable  sepsis. 

Causttcs. — The  treatment  of  cancer  of  the  breast  by 
various  pastes  or  caustics  has  no  place  in  surgery  and  should 
not  for  a  moment  be  countenanced.  Valuable  as  they  are 
in  certain  squamous  epitheliomata  of  the  face,  where  there  is 
little  tendency  to  glandular  infection  and  where  it  is  desirable 
to  avoid  disfigurement,  they  are  wholly  inadequate  to  cope 
with  acinous  carcinoma  in  an  organ  like  the  breast.  I  feel 
like  offering  an  apology  for  dignifying  them  by  mention  and 
only  do  so  because  they,  along  with  the  Roentgen  rays,  are 
still  given  an  amount  of  credit  altogether  out  of  proportion  to 
their  deserts. 


Carcinoma.  263 

The  trypsin,  or  trypsin-amylopsin,  treatment  of  carcinoma, 
based  upon  Beard's  theory  that  wandering  embryonal  cells 
develop  into  malignant  neoplasms  owing  to  the  fact  that  they 
have  escaped  the  destructive  action  of  certain  enzymes,  is 
mentioned  here  for  the  purpose  of  condemning  it  as  a  curative 
measure.  The  practitioner  should  guard  himself  well  against 
the  acceptance  of  such  extravagant  assertions  as  have  been 
made  by  a  few  enthusiasts  in  favor  of  this  treatment. 

This  is  not  the  place  to  discuss  Beard's  theory  of  the  Causa- 
tion of  cancer.  It  will  suffice  to  say  that  his  ideas  have  not 
been  accepted  in  their  entirety  by  those  best  qualified  to  judge 
of  the  matter. 

Concerning  the  trypsin  treatment  itself,  a  complete  analysis 
of  the  clinical  evidence  obtainable,  such  as  has  been  recently 
made  by  several  investigators,  notably  Dr.  Ellen  C.  Potter, 
of  Philadelphia,  shows  that  no  specific  action  is  exerted  by  the 
ferments.  Dr.  Potter  very  appropriately  calls  attention  to  the 
circumstance  that  changes  in  malignant  growths  similar  to 
those  supposed  to  have  been  produced  by  trypsin  have  occurred 
in  tumors  which  were  not  subjected  to  any  treatment  what- 
soever, and  have  also  been  observed  in  those  treated  with 
bacterial  vaccines. 

As  a  palliative  measure  in  inoperable  cases,  and  in  those 
in  which  operation  is  refused,  the  treatment  may  be  employed. 
It  is  stated  that  ulceration  has  been  limited  or  arrested,  that 
gain  in  weight  has  taken  place,  and  that  improvement  in  the 
general  condition  has  occurred  under  its  use.  These  con- 
siderations, if  true,  are  important.  At  all  events  they  are 
encouraging,  as  they  offer  a  possibility  of  adding  somewhat 
to  our  measures  of  relief  for  inoperable  cases. 

To  employ  such  a  novel  and  fanciful  method  of  therapy  in 
lieu  of  operation  would  be  highly  injudicious,  indeed  censurable. 

Oophorectomy,  which  was  first  recommended  by  Mr.  Beatson, 
has  occasionally  been   performed   as   a  therapeutic   measure 


264  Diseases  of  the   Breast. 

in  inoperable  mammary  cancer.  As  I  have  had  no  experience 
with  it,  I  cannot  do  better  than  quote  Mr.  Hugh  Lett,  who 
has  made  an  exhaustive  study  of  the  subject,  based  upon 
ninety-nine  cases. 

His  conclusions  are  as  follows: 

(1)  There  was  a  very  marked  improvement  in  23.2  per- 
cent, and  distinct,  though  less  marked,  improvement  in  13 
other  cases;  that  is,  36.4  percent  of  all  cases  operated  upon 
were  materially  benefited  by  the  operation.  If  the  patients 
who  were  more  than  50  years  old  are  omitted,  of  the  remaining 
75  cases  29.3  percent  showed  very  marked  improvement, 
and  nine  others  showed  distinct  improvement;  that  is  41.3 
percent  were  benefited  by  the  operation. 

(2)  In  successful  cases  the  benefit  has  been  great,  and  is 
mainly  shown  in  relief  from  pain,  marked  improvement  in 
health,  diminution  or  even  disappearance  of  the  growth, 
healing  of  ulcers,  and  prolongation  of  life. 

(3)  The  duration  of  the  improvement  is  not  very  often  stated, 
but  in  15  cases  the  improved  condition  was  maintained  for 
more  than  twelve  months  and  four  other  patients  had  good 
health  for  /\\  years  or  more. 

(4)  Oophorectomy  does  not  cure  the  disease,  for  in  all  the 
cases  in  which  the  growth  has  disappeared  after  the  operation 
it  has  subsequently  reappeared,  locally  or  elsewhere,  with  the 
exception  of  one  patient,  who  is  alive  and  free  from  recogniz- 
able cancer  at  the  present  time,  five  years  after  oophorectomy. 

(5)  The  most  favorable  age  for  operation  is  from  45  to  50; 
in  relatively  young  patients  it  should  be  given  a  further  trial, 
but  after  50  it  is  rarely  worth  doing.  The  fact  that  the  patient 
has  passed  the  menopause  does  not  contraindicate  the  operation. 

(6)  Thyroid  extract  is  not  a  necessary  factor  in  the  treat- 
ment, although  the  results  have  been  slightly  better  when  it 
has  been  given. 

(7)  Secondary   growths   in    the   viscera   contraindicate   the 


Carcinoma. 


265 


operation;  rapidity  of  growth,   or  an  early  recurrence  after 
the  primary  operation,  makes  the  prognosis  unfavorable. 

(8)  The  mortality  in  this  series  of  cases  is  high— a  little  over 
6  percent.  It  should  be  noted,  however,  that  the  actual 
cause  of  death  in  several  of  these  cases  may  be  regarded  as 
accidental;  in  two  the  fatal  issue  was  due  to  pulmonary  embo- 
lism and  in  one  to  acute  mania. 

Since  the  somewhat  tardy  acceptance  and  adoption  of  radical 
operative  measures  by  surgeons  in  general,  the  number  of  cures 
has  not  only  doubled,  but  quadrupled.  While  it  is  true  that 
occasional  permanent  cures  were  recorded  before  Moore's  paper 
in  1867,  they  were  accidental  and  fortuitous  and  must  have 
been  in  favorable  cases  with  only  a  primary  focus  in  the  breast, 
and  without  extensive  cutaneous,  muscular,  or  axillary  involve- 
ment. Further,  it  is  not  unlikely  that  many  of  the  cases  sup- 
posed to  have  been  cured  were  non-cancerous,  as  the  custom 
before  Moore's  paper  was  not  so  general  as  it  is  now  of  sub- 
mitting all  tumors,  after  their  removal,  to  the  microscope. 
Still,  a  careful  study  of  the  work  and  teachings  of  Astley  Cooper 
and  Velpeau  indicates  strikingly  their  familiarity  with  the 
anatomy  of  the  breast  and  its  outlying  rudiments,  the  gross 
pathology  of  the  disease,  and  their  appreciation  of  the  necessity 
for  a  free  excision  for  its  complete  eradication.  That  their 
work  in  mammary  cancer  stands  out  in  bold  relief  from  that 
of  their  contemporaries  is  nothing  more  than  should  be  expected 
of  two  such  masterful  minds,  making  as  lasting  an  impression 
upon  the  surgery  of  their  respective  countries,  and  the  world, 
as  it  is  given  to  men  to  do. 

Sir  Astley,  who  is  still  quoted  by  the  anatomists  for  his 
original  work  on  the  Anatomy  of  the  Mamma,  shows  in  his 
writings  an  accurate  knowledge  of  the  pathology  of  cancer: 
'The  scirrhus  tumor  is  not  all  of  the  disease;  there  are  roots 
which  extend  to  a  considerable  distance.  When  you  dissect 
a  scirrhus  tumor  you  see  a  number  of  roots  proceeding  to  a 


266  Diseases  of  the  Breast. 

considerable  distance;  and  if  you  remove  the  tumor  only,  and 
not  the  roots,  there  will  be  little  advantage  from  the  operation." 

The  great  clinician,  Velpeau,  spoke  positively  and  authori- 
tatively in  the  early  fifties,  reporting  a  score  of  cases  which 
had  not  only  passed  the  three  year  limit,  which  is  required 
to-day,  but  had  all  even  passed  a  five  year  limit;  some  of  the 
patients  had  lived  without  recurrence  for  twenty-five  years  after 
the  operation.  It  is  refreshing  to  read  such  words  as  these 
from  this  surgical  master  written  more  than  half  a  century  ago. 
"Des  Observations  tirees  de  ma  proper  pratique  demontrent, 
sans  contestation  possible,  l'existence  de  guerisons  radicales 
par  l'operation."  These  words  are  in  strange  contrast  with  the 
teachings  of  the  elder  Gross,  Paget,  and  VirChow,  his  con- 
temporaries in  America,  England  and  Germany,  and  other 
leading  surgical  pathologists  of  their  time. 

As  long  as  the  constitutional  origin  of  cancer  was  adhered 
to,  nothing  but  pessimism  could  permeate  those  who  con- 
templated its  removal  by  local  means. 

History  of  the  Operation  for  the  Cure  of  Mammary  Car- 
cinoma.— The  author  of  the  modern,  or  complete  operation, 
as  we  understand  it  to-day,  is  unquestionably  Mr.  Charles 
Moore,  formerly  a  surgeon  of  the  Middlesex  Hospital,  London, 
who,  in  1867,  published  a  paper,  remarkable  for  its  foresight 
and  keen  observation,  "On  the  Influence  of  Inadequate  Oper- 
ations on  the  Theory  of  Cancer."* 

That  others,  Velpeau  for  instance,  had  suspected  much  that 
was  true  cannot  be  doubted,  but  it  remained  for  Moore  to 
enunciate  clearly  and  distinctly  principles  which  are  to-day 
accepted  everywhere.  In  fact  his  views  were  so  much  at 
variance  with  the  prevailing  English  opinion  of  their  time, 
that  his  teaching  became  an  "  accepted  tradition  only  at  the 
Middlesex  Hospital,"  f  being  rejected  elsewhere  in  England 

*  Trans.  Royal  Med.  Chir.  Soc,  Vol.  I,  1867. 
f  Handley's  Carcinoma  of  the  Breast. 


Carcinoma.  267 

until  it  was  strenuously  advocated  in  1882,  fifteen  years  later, 
by  Sir  Mitchell  Banks,  of  Liverpool.  Meantime,  however,  the 
Germans,  Danes,  and  Austrians  had  been  actively  at  work  in 
putting  into  practice  the  teachings  of  Moore,  and  are  undoubt- 
edly entitled  to  the  credit  of  popularizing  the  complete  opera- 
tion.    In  this  work  Volkmann  was  foremost. 

S.  W.  Gross,  in  America,  was  quick  to  appreciate  the  ex- 
cellent work  of  German  surgeons,  and  in  the  late  seventies 
began  to  teach  and  practice  the  principles  laid  down  by  Moore. 
I  personally  assisted  him  in  such  operations  during  my  service 
as  interne  in  the  Jefferson  Hospital  during  1879-80. 

Moore's  teaching,  while  often  referred  to,  is  not  as  thoroughly 
understood  even  by  surgeons  and  teachers  as  it  should  be,  for 
it  was  he  who  shattered  and  utterly  demolished  the  constitu- 
tional theory  of  cancer,  which  had  been  accepted  by  the  pro- 
fession, and  had  made  operative  advance  wellnigh  impossible. 
He  insisted  that  the  entire  breast  should  be  removed  and  with 
it  all  involved  structures  such  as  skin,  fat,  pectoral  fascia, 
pectoral  muscle,  and  enlarged  lymphatic  glands.  Moreover, 
he  emphasized  that  it  should  be  done  in  such  a  way  that  the 
growth  was  neither  cut  into  nor  seen,  which  means  that  the 
diseased  structures  should  be  removed  en  masse — a  detail 
much  insisted  upon  of  late  without  giving  credit  to  Moore. 

Volkmann  was  probably  the  first  to  remove  the  pectoral 
muscles — major  in  a  series  of  38  cases,  minor  in  a  much 
smaller  number.  His  results  in  this  series,  though  the  cases 
were  more  advanced,  with  cancerous  infiltration  of  one  or  both 
muscles,  were  much  better  as  far  as  regional  and  local  recur- 
rences are  concerned,  than  in  his  milder  and  altogether  more 
favorable  cases  where  the  muscles  were  not  removed  because 
apparently  healthy. 

Heidenhain  recommended  that  the  fascia  covering  the 
pectoralis  major,  along  with  the  most  superficial  fibers  of  the 
muscle  itself,  be  removed.     He  believed  this  to  be  enough,  as 


268  Diseases  of  the   Breast. 

he  demonstrated  that  the  lymph  current  was  from  and  not  in 
the  direction  of  the  fascia.  It  should  not  be  forgotten,  how- 
ever, that  S.  W.  Gross  advised  and  practised  removing  the 
pectoral  fascia  in  1879,  and  that  Volkmann  had  done  so  in 
1875.  Thus  Heidenhain  only  emphasized  the  previous  teach- 
ings of  Moore  (1867),  Volkmann  (1875),  and  Gross  (1879), 
supplementing  them  with  careful  microscopical  studies  and  a 
better  understanding  of  the  lymph  currents.  More  credit 
than  the  facts  warrant  has  been  given  to  him  by  English  and 
American  surgeons. 

To  Halsted,  however,  is  due  the  credit  of  advising  the 
removal  of  the  muscles  in  every  case  regardless  of  infection. 
I  quote  from  his  paper  of  1894:  "The  pectoralis  major 
muscle,  entire  or  all  except  its  clavicular  portion,  should  be 
excised  in  every  case  of  cancer  of  the  breast,  because  the  oper- 
ator is  enabled  to  remove  in  one  piece  all  of  the  suspected 
tissues.  The  suspected  tissues  should  be  removed  in  one  piece, 
(1)  lest  the  wound  become  infected  by  the  division  of  tissues 
invaded  by  the  disease,  or  of  lymphatic  vessels  containing  cancer 
cells,  and  (2)  because  shreds  or  pieces  of  cancerous  tissue 
might  readily  be  overlooked  in  a  piecemeal  extirpation." 

Willy  Meyer*  about  the  same  time  advised  the  removal  of 
the  great  pectoral  and  urged  in  addition  that  the  lesser  pectoral 
be  also  removed  so  as  to  insure  a  more  complete  axillary  dis- 
section. 

Recent  investigations  by  Grossmann  and  Rotter  indicate 
clearly  the  wisdom  of  removing  the  muscles  always,  as  the 
major  muscle  is  involved  in  fifty  percent  of  all  cases,  and  it 
is  simply  impossible  to  remove  infected  tissue — lymphatic 
vessels  and  glands  between  them — without  doing  so.  Further, 
Rotter  insists  that  in  one-half  of  all  cases  there  will  certainly 
be  found  enlarged  lymphatic  glands  between  the  muscles 
which  cannot  be  recognized  with  the  pectorals  in  situ.     Gross- 

*  Medical  Record,  1894. 


Carcinoma.  269 

mann  succeeded  three  times  in  thirty  subjects  in  injecting  a 
lymph- bearing  vessel  from  the  mammary  gland,  which  per- 
forated the  great  pectoral,  running  between  it  and  the  pectoralis 
minor,  to  empty  finally  into  the  subclavian  or  topmost  axillary 
glands.  It  is  along  the  course  of  this  vessel  that  Rotter  found 
enlarged  glands. 

I  have  during  the  past  year  operated  upon  two  cases  with 
well  marked  retro-pectoral  enlarged  nodes,  calling  the  atten- 
tion of  my  assistants  to  them,  and  to  the  observations  of  Rotter. 
I  am  convinced  that  the  nodes  would  have  been  overlooked 
in  both  cases  had  not  the  great  pectoral  been  removed.  The 
experiments  of  Grossmann  and  Rotter  demonstrate  the  wisdom 
of  Halsted's  and  Meyer's  suggestion,  that  the  muscles  be 
removed  in  every  case  regardless  of  infection.  The  great 
pectoral  is  so  frequently  diseased  as  to  be  a  menace  if  left 
behind;  the  small  pectoral,  while  less  frequently  infected,  is  a 
barrier  to  one,  if  not  the  most  essential  step,  of  the  operation, 
namely,  a  thorough  axillary  dissection.  I  hold  that  it  is 
exceedingly  difficult,  if  not  impossible,  satisfactorily  to  clear 
the  space  of  Mohrenheim — between  the  upper  border  of  the 
tendon  of  the  pectoralis  minor  and  the  clavicle — of  fat,  glands, 
and  the  fascia  covering  the  vessels  without  injury  to  the  latter 
if  the  muscles  are  in  situ.  The  retention  of  the  muscles  is  of 
no  special  value,  so  far  as  the  future  usefulness  of  the  arm  is 
concerned,  and  their  removal  or  division  is  a  necessity  for 
thorough  and  accurate  work. 

I  know  there  are  some  who  conscientiously  think  that  they 
do  a  perfect  axillary  dissection  by  the  skilful  use  of  retractors — 
without  division  or  removal  of  the  muscles.  I  was  thus 
deceived  for  several  years,  but  now  fully  realize  that  my  work 
was  incomplete,  and,  moreover,  understand  recurrences  which 
were  at  the  time  both  disappointing  and  disheartening. 

There  are  from  three  to  twelve  lymphatic  glands  in  Mohren- 
heim's  space,  and  when  infected  these  nodes  receive  afferent 


2-jo  Diseases  of  the   Breast. 

vessels  from  all  of  the  axillary  glands  below.  These  glands 
are  intimately  associated  with  the  axillary  vein,  lying  to  its 
inner  aspect  at  the  point  where  it  receives  the  cephalic  vein. 
When  these  glands  are  enlarged  or  adherent  to  the  vessels, 
injury  is  easily  done  to  the  axillary  or  cephalic  vein,  unless 
their  removal  is  accomplished  by  careful  dissection.  To  leave 
them  behind  would  doom  inevitably  any  operation  to  failure. 

Another  reason  for  removing  the  lesser  muscle  is  the  occa- 
sional presence  of  enlarged  glands  between  the  vein  and  the 
artery,  which  can  only  be  reached  by  lifting  up  the  vein  and 
displacing  it  inwards.  This  can  easily  and  safely  be  done  by 
means  of  a  small  retractor,  provided  the  muscles  have  been 
removed  or  divided  and  then  retracted. 

Removal  of  the  fascia  surrounding  the  vessels  is  also  desir- 
able, and  presupposes  the  removal  of  the  muscles.  This 
step  certainly  requires  that  the  vessels  be  not  only  exposed, 
but  seen  in  a  good  light. 

I  have,  I  trust,  given  satisfactory  reasons  for  believing  that 
the  muscles  should  preferably  be  removed  in  every  case,  and 
have  shown  how  recent  anatomic  investigations  and  exper- 
iments demonstrate  forcibly  the  correctness  of  the  teaching  and 
clinical  judgment  of  Halsted  as  expressed  in  1894. 

That  the  removal  of  the  muscles  is  necessary  in  every 
case  no  one  will  or  should  maintain,  as  nearly  all  doing  work 
in  this  line  have  indubitable  cures  to  their  credit  where  the 
muscles  were  spared,  the  patients  having  long  since  passed  the 
period  of  probable  danger.  These,  however,  were  early  and 
favorable  cases,  and  the  removal  of  the  muscles  has  simply 
become  a  natural,  logical,  I  may  say,  inevitable  step  in  the 
evolution  of  the  operation. 

Supraclavicular  Glands. — In  1892  Halsted  first  practised 
removal  of  the  supraclavicular  glands,  and  in  his  paper  of 
1894  advised  that  it  be  done  as  a  routine  procedure.  Prior  to 
this  time  it  had  never  been  done  and,   moreover,  enlarged 


Carcinoma.  271 

cervical    glands    were    unanimously    considered    an    absolute 

bar  to  operation.     In  short,  such  a  case  was  thought  hopeless. 

Halsted's  suggestion  has  not  been  generally  adopted  by  Amer. 

ican  surgeons,  and  few  outside  of  Johns  Hopkins  Hospital 

have  removed  the  glands  of  the  neck  unless  palpably  enlarged 

or  unless  there  was  macroscopical  involvement  of  the  topmost 

axillary   glands.     Twenty-five   American   surgeons   to   whom 

I  addressed  the  question,  "Do  you  explore  the  supraclavicular 

space?"  answered  that  they  did  not  unless  there  was  palpable 

involvement.     Two  believe  that  it  should  be  done  more  often, 

on  account  of  recent  anatomical  discoveries.     In  this  opinion 

I  distinctly  concur,  and  have  made  it  an  invariable  rule  to 

explore  the  subclavian  triangle  if  the  tumor  is  a  peripheral 

one  in  the  upper  hemisphere,  since  the  discovery  by  Poirier 

and  Cuneo  of  a  set  of  lymphatic  vessels  which  drain  the  upper 

half  of  the  breast,  thence  passing  over  the  clavicle  to  empty 

into  the  supraclavicular  lymphatic  glands.     As  carcinomata 

are  so  often  located  in  the  upper  and  outer  quadrant  of  the 

breast,  I  should  say  that  it  would  be  safer  to  explore  the  neck 

in  a  majority  of  instances,  and  I  have  done  so  for  the  last  four 

years.     I  have  but  infrequently  found  it  involved;  still  I  do 

not  feel  that  my  duty  has  been  accomplished  until  the  incision— 

the  work  of  a  moment — is  made. 

Halsted  and  his  associates  at  the  Johns  Hopkins  Hospital  are 
removing  the  glands  of  the  neck  in  a  decreasing  number  of 
cases,  and  it  is  equally  true,  I  think,  that  other  American  sur- 
geons are  operating  upon  the  neck  in  an  increasing  number;  so 
that  Halsted's  original  position,  while  possibly  extreme,  has  been 
productive  of  good  and  brought  the  rest  of  us  up  to  the  mark. 
I  do  not  question  the  wisdom  of  the  procedure  if  there  is  notice- 
able enlargement  of  the  supraclavicular  glands,  if  the  sub- 
clavian chain  of  the  axillary  glands  are  at  ail  enlarged,  or  with- 
out such  enlargement  in  all  cancers  of  the  upper  hemisphere. 

Therefore,   recent  discoveries   entirely  support  Halsted   in 


272  Diseases  of  the  Breast. 

his  contention  that  the  neck  should  be  often  explored.  To 
give  his  exact  position  I  quote  from  a  letter  from  him:  "Of 
76  cases  cured  three  or  more  years,  the  supraclavicular  glands 
were  involved  (and  of  course  removed)  in  7  (9  percent). 
The  involvement  of  the  supraclavicular  glands  is,  of  course, 
much  greater  than  9  percent,  where  all  cases  in  which  the 
complete  operation  has  been  performed  are  included.  The 
proof,  then,  is  definite  and  ample  that  the  supraclavicular 
operation  is  indicated  in  many,  perhaps  most,  cases  of  carci- 
noma of  the  breast." 

I  cannot  say  that  I  have  cured  a  patient  with  neck  involve- 
ment, yet  one  lived  for  four  years  after  operation  without 
regional  recurrence  in  the  neck,  but  had  lethal  recurrences  in 
the  breast  incision.  Though  this  patient  was  not  cured,  her 
case  at  least  taught  me  that  very  decided  enlargement  of 
cervical  glands  low  down — they  altogether  made  a  mass  as 
large  as  a  small  lemon — does  not  necessarily  mean  inoper- 
ability.  If  glands  in  the  higher  triangles  are  involved,  the 
case  is  clearly  inoperable. 

Skin  Incision. — The  early,  frequent,  and  extensive  involve- 
ment of  the  skin  in  mammary  cancer  demanded,  and  should 
have  received,  in  the  incipiency  of  its  operative  treatment,  a  free 
removal  of  the  integument  covering  the  affected  breast.  This 
is  particularly  so  as  the  principal  lymph  channels  draining  the 
breast  are  known  to  be  in  the  skin;  Sappey  and  other  early 
anatomists  believed  that  nearly  all  such  vessels  were  to  be 
found  there.  Yet  in  spite  of  anatomy,  pathology  and  successful 
surgery  calling  for  a  free  removal  of  skin  as  the  prime  con- 
sideration— even  of  greater  moment  possibly  than  a  complete 
extirpation  of  the  gland  and  its  outlying  rudiments — we  still 
often  see  practised  the  antiquated  elliptical  incision  of  our 
forefathers.  So  little  of  the  infected  integument  is  removed 
by  these  incisions  that  subsequent  steps  in  the  operation, 
however  well  planned  and  carried  out,  are  necessarily  futile. 


Carcinoma.  273 

I  wish  to  state  positively  my  belief  that  the  excellent  results 
of  Gross  and  Banks  must  have  been  clue  to  the  free  removal 
of  skin  practised  by  each,  for  neither  of  them  sacrificed  the 
muscles— the  former  dying  in  1889,  five  years  before  Halsted 
suggested  it  as  a  routine  procedure  and  the  latter,  though  living 
until  1904,  never  believed  removal  of  the  muscles  necessary. 

I  was  the  guest  of  Sir  Mitchell  in  1904,  saw  him  brilliantly 
do  his  last  two  operations  for  mammary  cancer,  and  afterwards 
discussed  freely  with  him  the  value  of  removing  the  muscles. 
He  could  not  be  convinced  that  he  had  for  so  many  years 
omitted  an  important  step  in  an  operation  which  he  did  so 
much  to  perfect  and  with  which  his  honored  name  must  forever 
be  associated .     In  a  letter  written  me  a  few  days  before  his  death 
he  reviewed  his  work,  spoke  hopefully  of  the  operative  treat- 
ment of  cancer,  and  especially  insisted  upon  a  large  ring  incision. 
His  operations  reminded  me  of  Gross's  "dinner  plate  incision." 
To  give  some  conception  of  the  magnitude  of  Gross's  oper- 
ation, I  may  relate  that  I  was  assisting  him  one  day  when  he 
remarked  to  a  friendly  guest  present,  "I  will  show  you  my 
dinner  plate  incision."     It  was  an  enormous  breast,  the  wound 
made  unusually  large,  and  when  he  had  finished,  the  astonished 
onlooker  said  "dinner  plate,  h— 1,  it  looks  more  like  a  cart- 
wheel."    We  all  had  a  good  laugh  over  the  remark,  and  I  shall 
never  forget  the  surprise  of  his  friend  and  the  gratification  of 
Gross,  for  he  was  immensely  pleased  that  the  size  of  his  incision 
had  been  emphasized  even  with  language  more  forcible  than 
elegant. 

Gross  cured  21.5  percent  of  his  cases;  Banks  21  percent, 
and,  as  neither  did  what  is  to-day  regarded  as  a  good  axillary 
dissection,  because  neither  removed  the  muscles,  their  results 
must  have  been  largely  due  to  their  wide  removal  of  skin. 
Banks  usually  succeeded  in  closing  his  wound,  or  the  greater 
portion  of  it,  by  extensive  undermining  of  the  skin.  Gross 
allowed  his  wounds  to  heal  by  granulation.     I  have  never  seen 


274  Diseases  of  the  Breast. 

two  surgeons  operate  so  similarly  as  did  Banks  and  Gross  in 
their  breast  work,  and  it  is  shown  in  their  results,  21  and  21.5 
percent  of  cures  respectively. 

Halsted  makes  a  large  wound — almost  as  large  as  that  of 
either  of  the  above  mentioned  surgeons — and  supplements 
it  by  skin  grafting — a  distinct  improvement  and  advance. 
The  more  I  graft  the  better  am  I  satisfied  with  my  work,  for 
there  is  no  fear  of  probable  failure  to  secure  primary  union — a 
fear  which  I  believe  always  more  or  less  fetters  one  when 
making  any  of  the  flap  or  plastic  operations.  That  the  best 
of  them  may  often  succeed  admirably  in  meeting  all  require- 
ments, pathological  and  surgical,  there  is  no  question;  but  that 
they  sometimes  fail,  on  account  of  infected  skin  being  retained, 
is  certain. 

In  large  tumors  with  extensively  adherent  skin,  the  ring  or 
dinner  plate  incision  supplemented  by  skin  grafting,  preferably 
at  the  same  operation,  will  be  safer. 

The  disposition  of  some  to  graft  later  when  the  wound  has 
begun  to  granulate  has  little  to  recommend  it,  as  it  necessitates 
a  second  anesthesia  and  is  not  so  likely  to  succeed  as  when  done 
primarily.  That  there  is  somewhat  of  a  prejudice  against 
grafting  both  on  the  part  of  patients  and  profession  is  quite 
true.  The  scar  it  leaves  is  certainly  unsightly;  but  it  is  supple 
and  not  inclined  to  contract  and  bind  the  arm  as  nearly  all  of 
the  plastic  procedures  do.  I  distinctly  favor  it  and  am  resorting 
to  it  in  an  increasing  number  of  cases. 

The  next  decided  step  in  advance  was  the  removal  of  the 
fascia  covering  the  pectoralis  major  muscle.  As  already 
stated  the  credit  for  this  is  generally  ascribed  to  Heidenhain, 
who  undoubtedly  did  much  to  popularize  the  procedure,  and 
made  experiments  showing  that  the  lymph  current  was  from  and 
not  in  the  direction  of  the  fascia.  In  removing  the  fascia  he 
also  shaved  off  the  superficial  fibers  of  the  pectoralis  major. 
While  giving  full  credit  for  his  work,  I  have  shown  that  others 


Carcinoma.  275 

preceded  him  in  this  step  of  the  completed  operation.  More- 
over, that  he  overestimated  the  value  of  removing  the  fascia 
cannot  now  be  questioned  [in  view  of  more  recent  demon- 
strations, to  which  reference  has  already  been  made. 
In  all  tumors  adherent  to  the  costal  wall  and  in  those  cases 
with  retro-pectoral  enlarged  nodes  it  would  necessarily  be 
futile. 

Axilla. — When,  why,  and  by  whom  the  axilla  was  first 
explored  in  operations  for  mammary  cancer,  it  would  be 
difficult  to  say.  Moore  recommended  the  removal  of  axillary 
glands  which  were  palpably  enlarged  (1867),  and,  according 
to  Professor  Cheyne,  "Lord  Lister  in  the  late  sixties  began 
doing  a  very  free  operation,  which  included  in  most  cases  the 
free  removal  of  skin  and  ablation  of  the  pectoral  fascia  and 
axillary  glands."*  But  as  the  glands  are  palpably  enlarged  in 
"most  cases"  we  may  assume  that  Lister,  at  this  early  date, 
only  invaded  the  axilla  when  it  seemed  to  be  necessary.  That 
others  did  likewise,  there  is  abundant  testimony,  for  Volkmann 
in  1875  and  Kiister  before  him  believed  it  a  necessary  step. 
It  remained,  however,  for  the  younger  Gross  in  1880,  in  his 
"Tumors  of  the  Mammary  Gland,"  to  insist  that  the  axilla 
be  explored  in  every  case,  and  to  him  belongs  the  credit  of 
popularizing  this  step.  I  quote  his  words :  "  Even  if  I  should 
be  deemed  too  bold  in  recommending  that  the  axilla  be  attacked, 
when  it  is  apparently  free  from  disease,  surgeons  of  extended 
experience  will  certainly  agree  with  me  in  regarding  the  adipose 
tissue  as  being  largely  infiltrated  by  young  cells,  for  it  is  just 
precisely  in  corpulent  subjects  that  local  reproduction  is  most 
marked  along  the  line  of  the  cicatrix  of  partial  operations,  or, 
in  other  words,  in  the  fat  which  they  have  been  too  anxious 
to  save  in  order  that  they  might  secure  thick  and  seemly  flaps." 
Again  in  1888,  in  his  last  publication,  Gross  insisted  strongly 
upon  the  necessity  of  cleaning  out  the  axilla  in  every  case, 

*Handley's  Cancer  of  the  Breast,  p.  172. 


276  Diseases  of  the  Breast. 

calling  attention  to  outlying  lobules  of  breast  tissue  which  must 
not  be  overlooked.  I  know  that  he  did  so  during  my  student 
days  in  1878  and  my  internship  in  Jefferson  Hospital  in  1879. 
He  insisted  upon  what  every  one  now  believes,  that  enlarged 
glands  in  the  axilla,  especially  in  a  fat  subject,  may  elude  the 
most  careful  examination  before  the  axillary  space  is  opened 
and  explored.  Therefore,  he  explored  the  axilla  in  every 
case  of  cancer. 

The  fault  with  his  work  was  that,  far  ahead  of  his  time  as  it 
was,  it  did  not  go  far  enough,  as  he  only  reached  the  base  of  the 
axilla  and  depended  upon  a  piecemeal  extirpation.  The 
axillary  step  of  his  operation  would  not  be  called  thorough 
to-day,  for  I  repeat,  what  has  already  been  said,  that  a  thorough 
axillary  dissection  cannot  be  made  with  the  muscles  in  situ. 

The  defect  with  the  axillary  dissections  of  Gross,  and  I 
believe  with  those  of  all  others  up  to  the  time  of  Halsted,  lay 
in  the  fact  that  a  separate  incision  was  made  into  the  axilla, 
after  the  breast  had  been  removed  and  lymph-bearing  vessels 
had  been  cut  across.  Further,  it  was  a  small  wound,  per- 
mitting only  a  piecemeal  removal  of  palpably  enlarged  glands, 
good  thorough  work  under  the  guidance  of  the  eye  being  im- 
possible. It  was  a  long  step  in  advance,  but  it  fell  far  short 
of  the  mark. 

It  is  now  interesting  to  see  how  all  surgeons,  American, 
English,  German,  and  French  feared  invasion  of  the  axilla 
on  account  of  the  increased  risk.  The  mortality  from  the 
simple  operation  was  fifteen  percent,  and  double  that  when 
the  axilla  was  attacked.  For  this  reason  some  of  the  very 
best  English  authorities,  Butlin,  Treves,  and  others,  seriously 
argued  against  the  complete  operation.  Gross  admitted  the 
increased  danger,  but  advised  that  it  be  assumed  on  account 
of  the  fruitlessness  of  the  operation  without  it. 

How  aseptic  surgery  has  changed  things  and  made  really 
serious  and  able  disquisitions  of  one  time — and  that  not  so 


Carcinoma.  277 

very  long  ago — seem  trivial  to-day!  Truly  has  the  prediction 
of  Billroth  come  to  pass:  "I  should  not  be  surprised  if  an 
experienced  operator  were  to  succeed  in  doing  100  consecutive 
extirpations  with  but  a  single  death."  He  admitted  a  death 
rate  of  more  than  20  percent,  counting  all  of  his  cases,  and 
got  his  best  results  from  the  complete  operation  under  strict 
antisepsis  (1877-79),  his  mortality  then  dropping  to  5.8  per- 
cent. The  operative  mortality  in  2133  operations  performed 
since  1893  by  twenty-one  American  surgeons  reporting  to  me 
was  less  than  one  percent. 

In  231  operations  performed  under  strict  antiseptic  pre- 
cautions by  Lister,  Volkmann  and  Billroth,  the  mortality  was 
6  percent*  True,  these  operations  were  done  in  the  decade 
from  1 8  70-1 880,  but  all  were  in  the  hands  of  the  best  exponents 
of  antiseptic  surgery. 

The  best  results,  secured  from  any  standpoint,  have  been 
gained  since  Halsted's  paper  in  1894,  which  may  justly  be  said 
to  mark  the  second  epoch  in  surgery  for  mammary  cancer. 
Twenty-seven  years  after  Moore's  publication,  it  re-affirmed 
and  with  greater  emphasis,  because  it  was  supported  by  incon- 
trovertible statistics,  every  position  taken  by  Moore,  going 
many  steps  in  advance  of  him  and  every  one  else. 

The  axillary  feature  of  Halsted's  operation  is  its  best;  all 
glands,  fat  and  fascia  covering  vessels  and  muscles  are  removed 
en  masse,  and  nothing  left  from  apex  to  base  but  vessels  and 
nerves.     A  piecemeal  extirpation  is  to  be  condemned. 

Removal  0}  Deep  Fascia. — In  1904,  Mr.  Handley,  in  a  paper 
read  before  the  Surgical  Section  of  the  British  Medical  Associa- 
tion, advised  a  still  more  extensive  operative  procedure  than  had 
hitherto  been  practised,  founded  upon  his  theory  of  permeation 
of  cancer  cells  along  the  deep  fascia.  I  was  much  impressed 
by  hearing  his  paper  and  the  discussion  which  followed  it, 
and  since  then  have  myself  practised  a  freer  removal  of  the  deep 

*  Williams'  Diseases  of  the  Breast,  p.  362. 


278  Diseases  of  the  Breast. 

fascia  than  before.  I  believe  he  is  right  in  advocating  that  the 
fascia  covering  the  upper  part  of  the  rectus  and  external  oblique 
muscles  be  removed  to  a  greater  extent  than  heretofore.  I 
always  remove  the  fascia  covering  the  serratus  and  subscap- 
ulars muscles. 

I  am  hardly  prepared,  however,  to  accept  the  suggestion 
given  in  his  recent  excellent  treatise  on  cancer,  that  the  digita- 
tions  of  the  serratus  magnus  and  external  oblique  muscles  be 
removed.  It  seems  to  me  that  the  limits  of  the  operation  have 
about  been  reached  and  that  to  carry  it  out  conscientiously 
in  every  detail  the  complete  operation,  as  we  now  understand 
it,  will  require  from  one  to  two  hours,  according  to  the  rapidity 
of  the  work.  Moreover,  I  am  not  convinced  of  the  necessity 
for  removing  these  muscles  as  a  routine  procedure.  Car- 
cinomata  are  usually  located  in  the  upper  and  outer  quadrant 
of  the  gland,  a  small  part  of  which  lies  in  contact  with  the 
serratus  and  does  not  touch  the  external  oblique.  It  would, 
therefore,  seem  a  work  of  supererogation  to  remove  even  a 
portion  of  these  muscles  unless  adherence  to  the  costal  wall 
has  taken  place.  In  large  growths  of  the  lower  and  outer 
quadrant,  especially  if  the  gland  is  adherent  to  the  costal 
wall,  and,  therefore,  in  contact  with  both  muscles,  the 
fascia  covering  them  should  certainly  be  removed  and  along 
with  it  the  superficial  fibers  of  the  muscles  themselves.  I 
would  not  be  disposed  to  remove  the  digitations  in  their 
entirety,  as  it  would  seem  to  me  that  any  case  so  far  advanced 
as  to  make  this  necessary  is  hopeless  and  beyond  the  reach  of 
surgery. 

Removal  of  the  Breast. — Since  Stiles's*  valuable  contribution 
to  the  surgical  anatomy  of  the  breast,  it  is  reasonably  certain 
that  in  many,  perhaps  most,  operations  prior  to  that  time  the 
diseased  mammne  were  incompletely  removed.     He  showed  by 

*  Edinburgh  Medical  Journal,  1892. 


Carcinoma.  279 

careful  investigation  and  his  nitric  acid  test,*  that  the  gland  is 
a  much  more  extensive  structure  than  was  formerly  believed, 
and  that  the  periphery  and  detached  portions  were  necessarily 
left  behind  after  any  of  the  usual  operative  procedures  of  the 
time.  His  work  was  most  valuable  and  contributed  greatly 
to  the  "complete  operation"  of  the  present  day.  He  clearly 
demonstrated  that  the  gland  often  extends  up  nearly  to  the 
clavicle,  always  considerably  below  the  margin  of  the  pectoralis 
major,  overlapping  the  serratus  magnus,  external  oblique  and 
rectus  muscles.  Externally  it  is  prolonged  into  the  axilla, 
making  a  well-marked  axillary  tail. 

Stiles's  paper  was  a  positive  demonstration  that  nearly  all 
of  the  elliptical  incisions  formerly  employed  were  inadequate 
for  the  removal  of  the  breast  in  its  entirety.  His  investigations 
strongly  emphasized  the  necessity  of  either  a  very  free  removal 
of  skin  as  practised  by  Banks  and  Gross  in  their  circular 
incisions,  or  an  elliptical  incision  which  is  supplemented  by 
extensive  undermining  of  the  integument  and  free  removal  of 
para-mammary  fat. 

Para-mammary  Fat. — More  has  been  said,  perhaps,  than  is 
necessary  about  the  removal  of  fat,  para-mammary,  axillary, 
and  in  the  flaps.  Yet  it  is  of  the  greatest  importance  to  remove 
the  fat,  because  in  doing  so  the  very  small  lymphatic  glands 
are  at  the  same  time  removed  and  might  be  overlooked  if  the 
fat  were  left  behind.  The  axillary  fat,  as  has  already  been 
said,  should  go,  every  particle  of  it,  along  with  the  fascia.  If 
the  circular  incision,  the  racquet  incision  of  Warren,  Jackson's 
method,  and  the  best  of  the  numerous  elliptical  incisions,  to 
be  described  later  on,  be  rightly  done,  little  uneasiness  need  be 
felt  concerning  the  para-mammary  fat.  It  will  have  been 
attended  to  in  the  planning  of  the  preliminary  incision. 

fWash  the  breast  in  running  water  to  free  it  from  blood,  immerse  it  in  a  5 
percent  solution  of  nitric  acid  for  ten  minutes,  wash  again  and  then  put  it  in 
methyl  alcohol,  The  epithelial  structures  assume  a  dull,  opaque  grayish  hue, 
which  differs  markedly  in  appearance  from  the  stroma.  (Edinburgh  Medical 
Journal,  June,  1892.) 


280  Diseases  of  the   Breast. 

We  have  traced  the  several  important  steps  of  the  operation 
for  cancer  of  the  breast  through  their  various  evolutionary 
changes  until  we  now  have  the  complete  operation  as  it  is 
understood  and  practised  by  the  best  surgeons  the  world  over. 
Briefly  to  summarize,  they  are:  A  free  removal  of  skin;  com- 
plete extirpation  of  the  breast  with  the  para-mammary  jat; 
removal  of  the  pectoral  muscles;  a  complete  dissection  of  the 
axilla;  and  a  sufficiently  free  removal  of  deep  fascia  covering 
the  rectus,  serratus  magnus,  and  external  oblique.  All  tissues 
must  be  removed  in  one  piece  and  without  undue  or  forcible 
manipulation,  so  as  to  avoid  the  possibility  of  expressing  cancer 
cells  from  severed  lymphatic  vessels,  thereby  incurring  the  risk 
of  inoculating  the  wound. 

Relative  Importance  of  the  Several  Steps. — It  would,  of  course, 
be  profitable  to  know  just  what  each  step  in  the  " completed" 
operation  has  contributed  to  the  sum  total  of  cures.  I  think 
that  we  may  rightly  use  such  a  term,  as  operative  measures 
have  become  about  as  extensive  as  they  well  can  be  if  indeed 
they  have  not  reached  the  very  Ultima  Thule  of  justifiable 
surgery.  This  can  never  be  known  definitely.  Valuable  in- 
formation, however,  is  gained  by  taking  the  statistics  of  the 
best  men  of  different  decades  and  contrasting,  so  far  as  is 
practicable,  the  differences  in  their  methods  of  operating. 
The  first  statistics  of  real  value  were  those  of  Gross  in  1880, 
compiled  largely  from  the  Danish,  German  and  Austrian 
surgeons,  who  were  the  first  to  recognize  the  possibilities  of 
Moore's  operation;  these  yielded  9.05  percent  of  cures  pass- 
ing the  three  year  limit  without  regional  or  internal  recur- 
rence. At  this  time  the  breast  was  incompletely  removed 
because  a  small  incision  was  made,  the  axilla  was  not  opened 
unless  palpably  the  site  of  metastasis,  and  then  only  a  few 
enlarged  glands  were  pulled  out  by  blunt  finger  dissection. 

The  next  papers  of  great  importance  were  published  in  1888 
by  Gross  and  Sir  Mitchell  Banks  respectively,  and  it  will  be 


Carcinoma.  281 

seen  that  these  surgeons  reach  the  same  theoretical  and  prac- 
tical results,  21.5  and  2 1 .  No  two  men  ever  operated  more  ali ke . 
Both  made  a  large  wound,  both  removed  the  pectoral  fascia, 
neither  sacrificed  the  muscles,  and  both  did  a  fairly  good  dis- 
section of  the  axilla;  very  good  at  the  base,  indifferent  at  the 
middle,  and  wanting  at  the  apex  or  space  of  Mohrenheim. 

W.  T.  Bull,  in  1895,  published  his  own  statistics  in  118  cases, 
and  attained  somewhat  better  results  than  Gross  and  Banks 
had  done  (26.6  percent  of  cures).  No  series  of  cases  had  ever 
been  more  carefully  and  conscientiously  followed  up,  and  such 
results  in  the  practice  of  this  thoroughly  well-known,  conser- 
vative, and  able  surgeon  did  much  to  give  an  impetus  to  radical 
operations.  Moreover,  he  stated  with  greater  definiteness  the 
axillary  condition  in  his  cases  than  others  had  done,  and 
measured  more  accurately  its  effect  upon  the  result  of  operation. 
His  method  of  operating  was  very  similar  to  that  of  Gross  and 
Banks  in  every  respect  save  one— he  did  a  much  better  and  a 
more  thorough  axillary  dissection  than  either  of  them  and 
removed  so  far  as  it  was  possible,  without  sacrificing  the  muscles, 
everything  en  masse.  Therefore,  it  would  seem  fair  to  state 
that  his  additional  five  percent  of  permanent  cures  was  due 
to  more  thorough  work  in  the  axilla. 

Having  seen  all  three  operate  and  knowing  that  each  did 
exactly  the  same  operation  up  to  this  step,  I  am  convinced  that 
Bull  was  entitled  to  the  advantage  shown  by  his  statistics. 
Hence,  we  are,  I  think,  amply  warranted  in  saying  that  a  fair 
axillary  dissection  will  save  double  the  number  of  cases  (21.5 
percent)  that  will  follow  removal  of  the  breast  alone  (9.5  per- 
cent) and  that  a  good  axillary  dissection  will  save  an  additional 
five  percent  (26.6  percent)  of  such  patients.  Of  Bull's 
cured  patients  40  percent  had  decided  axillary  involvement 
before  operation.  Of  the  entire  number  operated  more  than 
61  percent  had  axillary  involvement. 

Halsted  has  just  published  a  report  of  232  cases  operated 


282  Diseases  of  the  Breast. 

upon  by  himself  and  assistants  in  the  Johns  Hopkins  Hospital. 
There  were  38.3  percent  free  from  recurrence  three  years 
or  longer.  In  14  cases  metastasis  appeared  later  than  three 
years;  in  two,  more  than  six  years  after  operation  and  in  one 
eisfht  vears  after. 

o 

This  last  report  of  Halsted  is  very  satisfactory,  inasmuch 
as  his  operation  has  now  been  on  trial  for  16  years.  It  also  is 
instructive  as  pointed  out  under  prognosis  in  showing  clearly 
the  advantage  from  early  operation  before  there  is  involvement 
of  the  axilla. 

It  will  be  interesting  to  see,  should  the  theory  of  Mr.  Handley 
meet  with  general  acceptance  and  his  suggestion  for  still  more 
extensive  operative  measures  be  followed  out  in  practice,  if 
the  permanent  results  warrant  the  increased  primary  risk. 

Technique. — x\s  a  complete  operation  for  carcinoma  of  the 
mammary  gland  is  one  of  some  magnitude,  due  preparation 
should  be  given  the  patient  beforehand.  A  general  bath  should 
be  taken  the  evening  before,  it  being  followed  by  a  careful 
shaving  of  the  axilla,  and  the  skin  of  the  thorax,  axilla,  and  arm 
thoroughly  cleansed  with  antiseptic  soap,  bichloride  solution 
1-1000,  ether  and  alcohol.  Then  the  breast  and  adjacent 
parts  involved  in  the  operation  are  to  be  covered  during  the 
night,  and  up  to  the  time  of  operation,  with  aseptic  gauze. 

A  mild  purge  of  calomel  is  taken  the  afternoon  or  evening 
before,  and  if  the  bowels  have  not  acted  freely  by  7  A.  M.  the 
day  of  the  operation,  an  enema  is  given.  Free  catharsis  is 
to  be  avoided,  as  these  patients  are  frequently  old,  and  excessive 
purgation  may  add  to  the  shock  usually  incident  to  so  pro- 
longed an  operative  procedure. 

The  operation  should  preferably  be  set  for  10  A.  M.,  when  the 
light  is  good — a  necessity  for  a  thorough  axillary  dissection. 
Prolonged  operations  in  the  afternoon  must  at  times  be  fin- 
ished by  artificial  light.  Moreover,  they  occasion  a  day  of 
anxiety  to  the  patient. 


Carcinoma.  283 

The  temperature  of  the  operating  room  should  not  be  less 
than  7  20  F.  and  it  is  better  to  either  place  the  patient  upon  a 
heated  table  or  surround  her  with  hot  water  bottles,  being  care- 
ful, of  course,  that  burning  of  the  skin  does  not  occur.  My 
invariable  custom  is  to  administer  J  to  \  of  a  grain  of  morphia 
with  Ti  0"  of  atropine  hypodermatically  one  hour  before  beginning 
ether.  This,  I  am  convinced,  tranquilizes  the  patient,  lessens 
the  amount  of  the  anesthetic,  minimizes  shock,  and  materially 
contributes  to  post-operative  comfort.  The  preliminary  hypo- 
dermic is  particularly  called  for  if  there  be,  as  is  so  often  the 
case,  accompanying  bronchial,  cardiac  or  renal  complications. 
The  ether  is  always  given  slowly  and  by  the  drop  method. 

The  operating  room  should  be  well  lighted,  and  if  the  day 
is  cloudy  a  good  electric  light  will  materially  aid  in  the  axillary 
dissection. 

Besides  the  anesthetist,  three  assistants  are  necessary.  The 
first  assistant  stands  opposite  to  the  operator,  giving  necessary 
assistance  at  every  stage  of  the  operation.  He  should  be  ex- 
perienced, collected,  and  thoroughly  familiar  with  the  various 
steps  of  the  operation,  for  upon  him  largely  will  depend  both 
the  rapidity  and  thoroughness  of  the  work.  The  second  assist- 
ant stands  on  the  same  side  as  the  operator,  holding  the  arm 
and  moving  it  from  time  to  time  as  requested.  The  third 
assistant  handles  the  instruments,  and  I  find  that  a  nurse  is, 
as  a  rule,  defter  in  picking  up  forceps,  ligatures,  threading 
needles,  etc.,  etc.,  than  the  average  house  surgeon.  Always  a 
little,  and  sometimes  a  great  deal  of  time,  can  be  saved  in  this 
operation  by  a  good  third  assistant.  All  should  wear  rubber 
gloves.  A  fourth  assistant  may  be  held  in  reserve  in  the  event 
of  pronounced  shock,  so  that  enteroclysis  or  hypodermoclysis 
may  be  promptly  given  without  in  any  way  delaying  the  oper- 
ation.    This  rarely,  though  sometimes,  is  necessary. 

Instruments. — At  least  two,  preferably  three,  very  sharp 
scalpels,  two  dozen  hemostatic  forceps,  smooth  and  toothed 


284  Diseases  of  the  Breast. 

dissecting  forceps,  large  and  small  straight  scissors,  large  and 
small  curved  scissors,  Allis's  or  Mayo's  blunt  dissector,  retrac- 
tors large  and  small,  straight  and  curved  needles,  and  a  fenes- 
trated rubber  drainage  tube  should  be  at  hand. 

As  skin  grafting  is  so  often  required,  either  a  sharp  razor, 
or,  what  is  better,  a  medium  size  amputating  knife,  tenacula 
and  two  sterilized  blocks  of  wood  for  making  the  skin  of  the 
thigh  tense  should  be  in  readiness.  It  is  unnecessary  to  prepare 
the  thigh  for  grafting  before  the  operation,  as  it  is  quickly 
done  when  necessary  by  the  fourth  assistant  without  delaying 
matters,  and  if  done  beforehand  disturbs  somewhat  the  mental 
tranquility  of  the  patient  and  emphasizes  in  her  mind  the 
magnitude  of  the  operation.  She  should  be  told,  however, 
that  it  may  be  necessary. 

Ligatures. — I  prefer  fine  Pagenstecher  for  ligatures.  Silk, 
of  course,  will  answer  very  well,  but  the  tensile  strength  of 
linen  is  greater  and  it  is  as  well  or  better  taken  care  of  by  the 
tissues.  Catgut  prepared  by  either  the  Bartlett  or  Claudius 
method  may  be  used  should  a  strictly  absorbable  material 
be  preferred. 

Sutures. — For  closing  the  wound  I  prefer  horse  hair,  using 
the  continuous  suture  after  the  buttonhole  method,  unless  there 
is  too  much  tension,  in  which  event  supplementary  interrupted 
sutures  of  Pagenstecher  or  silk  are  placed  where  they  are  most 
needed  or  used  throughout. 

Dressing. — An  abundant  dressing  of  sterile  gauze  should 
cover  the  wound,  thorax,  axilla,  arm,  and  neck.  The  dressing 
should  be  so  applied  as  to  make  firm  pressure,  in  the  axilla 
especially,  so  as  to  obliterate  any  dead  space.  This  is  of  much 
importance  and  greatly  enhances  the  chances  of  primary  union. 
As  the  dressing  must  be  changed  at  the  end  of  24-48  hours,  so 
that  the  drainage  tube  may  be  removed  and  dry  gauze  sub- 
stituted for  that  previously  used,  which  will  be  found  quite 
wet  in  the  vicinity  of  the  tube,  plaster-of-Paris  or  other  imper- 


PLATE  XLIII 


Paget's  Disease  of  the  Nipple 


Carcinoma.  285 

meable  dressings  should  be  omitted.  They  are  quite  unneces- 
sary, their  application  always  time-consuming,  and  it  may  be 
a  matter  of  moment  in  the  event  of  secondary  hemorrhage  to 
reach  and  open  the  wound  as  quickly  as  possible.  Moreover, 
they  prevent  the  prompt  recognition  of  hemorrhage,  save  by  the 
symptoms,  which  means  that  a  great,  perhaps  a  lethal  amount 
of  blood  might  be  lost  before  the  nurse  would  suspect  what 
was  wrong. 

As  soon  as  the  dressings  are  applied  the  patient  should  be 
placed  on  a  carriage  covered  with  warm  blankets  and  quickly 
removed  to  her  room,  the  temperature  of  which  should  be  at 
least  750  F. — preferably  8o°. 

The  axillary  or  rectal  temperature  should  at  once  be  taken 
and  will  usually  indicate  a  fall  of  several  degrees.  An  axillary 
temperature  of  950  is  by  no  means  rare  and  I  have  often  seen 
it  less.  As  a  rule  nothing  further  will  be  required.  In  the 
event,  however,  of  a  markedly  subnormal  temperature  accom- 
panied by  other  symptoms  of  shock,  an  enema  of  hot  coffee 
and  saline  solution  should  be  given,  the  foot  of  the  bed  elevated, 
and  a  further  hypodermatic  injection  of  atropine  administered, 
accompanied  by  morphia  if  the  patient  is  suffering  pain.  In 
the  most  severe  cases  hypodermoclysis  with  adrenalin  should 
be  given  in  the  thigh,  so  as  not  to  disturb  the  dressing  over  the 
thorax. 

For  strychnia  as  a  remedy  in  shock  I  have  little  appreciation 
and  believe  that  in  many,  perhaps  most,  cases,  it  is  harmful. 
It  is  only  in  the  relatively  rare  cases  where  the  pulse  is  slow 
and  wavering,  the  shabby  pulse  as  it  has  been  called,  that  it  is 
desirable  to  increase  the  frequency  and  force  of  the  systole  by 
strychnia.  Then  it  acts  favorably  and  promptly.  In  the  small 
and  frequent  pulse  so  usual  in  shock,  strychnia  exaggerates  the 
condition  and  "lashes  the  tired  horse." 

Even  though  there  be  no  shock,  it  is  my  invariable  custom 
to  order  that  enteroclysis  be  given  every  four  hours  during  the 


286  Diseases  of  the   Breast. 

first  48  hours,  or  until  the  patient  is  able  to  take  plenty  of 
fluids  by  the  stomach.  Six  to  eight  ounces  of  normal  salt 
solution  with  a  desertspoonful  of  the  infusion  of  digitallis  will 
usually  be  retained  without  difficulty.  This  quenches  thirst, 
flushes  out  the  kidneys,  and  in  every  way  subserves  the 
patient's  comfort.  I  consider  it  too  helpful  to  be  omitted  in 
any  case.  If  there  is  not. great  tension  upon  the  flaps  the 
preliminary  dose  of  morphia  may  be  all  that  is  necessary.  It 
is  not  unusual,  however,  for  a  second  dose  to  be  required  in 
the  evening  or  night  following  the  operation  if  tension  upon 
the  flaps  has  been  made  in  closing  the  wound. 

Operation. — I  prefer  ether  anesthesia  given  cautiously  by  the 
drop  method,  though  not  infrequently  use  chloroform  if  there 
is  contra-indication  to  ether.  It  is  of  importance  in  the  first 
instance  that  the  anesthetist,  before  beginning  the  ether,  adjust, 
if  it  has  not  already  been  done,  a  rubber  cap  to  the  patient's 
head,  the  hair  being  done  up  on  top.  This  keeps  the  hair 
from  possibly  getting  into  the  wound. 

Secondly,  he  is  instructed  to  lighten  the  anesthesia  from 
time  to  time  after  the  incisions  through  the  skin  have  been 
made.  Light  anesthesia  suffices  during  the  occasionally 
prolonged  axillary  dissection. 

Thirdly,  he  should  be  warned  to  keep  his  own  and  the 
patient's  head  turned  to  the  opposite  side  so  as  to  prevent 
their  breathing  into  the  wound  or  possibly  infecting  it  with 
saliva,  vomitus,  etc.  He,  as  well  as  all  others  taking  part  in 
the.  operation,  should  wear  a  mask  and  take  every  precau- 
tion that  other  assistants  do  to  insure  sterility.  It  would 
appear  better  to  [have  a  screen  or  shield,  which  will  effect- 
ually prevent  either  the  patient  or  the  anesthetist  from  con- 
taminating the  wound.  It  is,  however,  inconvenient;  prevents 
the  operator  from  looking  into  the  face  of  the  patient 
and  the  anesthetist  from  observing  her  movements,  a  hint 
for  deeper  anesthesia,  or  from  seeing  the  dark  color  of  the 


Carcinoma.  287 

blood  incident  to  profound  narcosis.  Without  a  most  ex- 
perienced and  trustworthy  anesthetist,  the  screen  is  a  disad- 
vantage, as  infection  of  the  wound  by  either  patient  or  anes- 
thetist must  be  infrequent  and  the  risks  of  anesthesia  are 
certainly  increased  by  the  use  of  the  screen. 

I  shall  describe  the  steps  of  the  operation  I  now  do,  and 
which,  I  think,  embraces  the  good  features  of  the  most  ap- 
proved and  accepted  procedures  for  carcinoma  of  the  breast. 
A  straight  incision  is  made  beginning  one  inch  below  the  clavicle, 
two  finger-breadths  from  and  parallel  with  the  sulcus  between 
the  deltoid  and  the  clavicular  portion  of  the  pectoralis  major. 
It  extends  well  below  the  free  edge  of  the  pectoralis  major 
muscle,  and  in  extent  will  usually  be  from  five  to  six  inches  or 
more,  according  to  the  stature  of  the  subject  and  the  size  of  the 
breast.  (Plate  XLIII  A.)  It  is  rapidly  carried  down  through 
skin  and  superficial  fascia  to  the  fascia  covering  the  great 
pectoral  muscle.  No  hemorrhage  of  consequence  is  encount- 
ered thus  far.  I  prefer  to  place  this  incision  not  too  close  to 
the  arm,  for,  in  my  judgment,  incisions  extending  on  to  the 
arm  result  in  cicatrices,  which  often  seriously  interfere  with 
the  future  usefulness,  and  less  frequently  cause  edema  of  the 
limb. 

The  index  finger  of  the  left  hand  is  now  introduced  beneath 
the  lower  border  of  the  tendon  of  the  great  pectoral  muscle 
and  made  to  emerge  above  its  upper  border,  or  in  the  interval 
between  the  costal  and  clavicular  portions,  if  one  wishes  to  re- 
move only  the  costal  origin  of  the  muscle,  and  division  of  the  ten- 
don effected  at  or  near  its  insertion  into  the  humerus.  This  may 
be  facilitated  by  dissecting  up  the  external  flap  slightly  and  using 
retractors.  I  myself  see  no  reason  for  removing  the  clavicular 
portion  in  the  average  case,  and,  therefore,  leave  it  unless  the 
growth  is  peripheral  and  in  the  upper  hemisphere.  Then  unques- 
tionably the  entire  muscle  should  be  sacrificed.  (Plate  XLIV.) 
Only  a  slight  dissection  will  be  necessary  to  discover  the  lower 


288  Diseases  of  the  Breast. 

edge  of  the  tendon  of  the  pectoralis  minor.  This  should  be 
clearly  identified  and  separated  from  the  fascia  covering  the 
tendon  and  below  it.  Otherwise  the  long  thoracic  artery 
which  runs  in  the  fascia  parallel  with  and  just  below  the 
tendon  may  easily  be  wounded. 

The  index  finger  is  now  introduced  underneath  the  muscle 
and  made  to  emerge  at  its  upper  border.  Lifting  up  the 
muscle,  the  tendon  is  made  tense  and  prominent,  so  that  it 
can  readily  be  seen  that  no  other  tissues  are  included  with  the 
tendon.  The  acromio-thoracic  artery  runs  just  above  and 
parallel  with  this  tendon,  and,  being  a  branch  of  considerable 
size,  might  cause  some  little  embarrassment  if  it  were  cut  at 
this  stage  of  the  operation.  It  is  divided  at  its  insertion  into  the 
coracoid  process.  (Plate  XLV.)  Therefore,  we  have  the  acromio- 
thoracic  artery  parallel  with  and  just  above  the  upper  border 
of  the  minor  pectoral  tendon;  the  long  thoracic  parallel  with 
and  just  below  its  lower  border.  Both  can  easily  be  avoided 
if  care  is  taken.  I  have  never  as  yet  wounded  either  vessel,  nor  is 
there  excuse  for  doing  so.  Both  muscles  retract  inward  as  soon 
as  their  respective  tendons  are  severed.  This  at  once  uncovers 
the  axilla  and  makes  its  subsequent  thorough  dissection  easy. 
The  costo-coracoid  membrane  is  now  opened  and  largely 
sacrificed,  which  gives  ready  access  to  the  subclavicular  fat 
at  the  apex  of  the  axilla — in  the  space  of  Mohrenheim.  In 
removing  a  part  of  the  costo-coracoid  membrane,  the  cephalic 
vein  at  the  upper  and  outer  aspect  of  the  wound  must  not  be 
wounded.  There  is  also  in  the  fascia  a  branch  of  the  acromio- 
thoracic  which,  with  its  accompanying  vein  should  be  clamped 
and  tied.  A  nerve  supplying  the  pectoral  muscle  may  as  well 
be  sacrificed  now,  as  it  necessarily  must  be  later  on  when  the 
muscles  are  removed.     (Plate  XL VI.) 

The  dissection  is  begun  at  the  apex  of  the  axilla  and  must  be 
most  carefully  conducted  lest  injury  be  done  to  either  the 
axillary  vein  or  the   acromio-thoracic   artery.     It   should   be 


Carcinoma.  289 

from  above  downward,  though  this  is  perhaps  somewhat  more 
difficult  than  making  the  dissection  from  below  upward. 

In  the  removal  of  the  fat  and  fascia  in  the  upper  third  of 
the  axilla,  the  finger,  covered  by  several  thicknesses  of  gauze, 
will  be  all  that  is  necessary.  Instruments  are  rather  dangerous, 
unless  used  most  cautiously.     Moreover,  they  are  unnecessary. 


^k^!l^-^S^Se^^;^,,j, ,  ,,    ,    .     ■■M<wmMrmw®®te^~jiy? 


Fig.  36. — Allis's  blunt  dissector. 


I  now  carefully  make  an  incision  through  the  fascia  to  the 
outer  side  of  the  axillary  vessels  simply  to  start  the  dissection 
from  without  inward.  This  is  made  to  the  extent  of  the 
lower  two-thirds  of  the  axilla  and  not  in  the  upper  third  where 
it  is  dangerous  to  cut.  I  continue  the  dissection  largely  with 
gauze,  but  Allis's  or  Mayo's  blunt  dissectors  may  be  used 


Fig.  37. — Mayo's  blunt  dissector. 

freely  and  are  most  helpful.  (Figs.  36  and  37.)  Occasionally 
a  cut  with  scissors  or  a  sharp  knife  facilitates  the  dissection. 
The  instrument  of  Charles  H.  Mayo  is  more  than  a  blunt  dis- 
sector for  it  can  also  be  used  as  a  scissors  and  is  most  valuable 
in  economizing  time,  making  a  change  of  instruments  unneces- 
sary. 

As  the  sheath  and  fat  are  removed  from  the  vessels  we  come 
down  upon  the  acromial,  long  and  alar  thoracic  branches, 
19 


290  Diseases  of  the  Breast. 

and  the  subscapular  branch  of  the  axillary  artery,  in  the 
order  named,  from  above  downward,  which,  with  their  accom- 
panying veins  are  to  be  carefully  clamped  in  two  places  and 
divided  between.  The  proximal  ends  are  ligated.  In  this 
way  the  subsequent  hemorrhage  is  materially  lessened;  in  fact 
it  is  surprising  how  little  blood  will  be  lost  during  so  prolonged 
and  extensive  a  surgical  procedure. 

The  enlarged  lymphatic  glands  will  usually  be  found  at 
the  base  of  the  axilla  between  the  latissimus  dorsi,  teres  major, 
and  subscapularis  muscles  posteriorly;  the  serratus  magnus 
internally;  and  inferior  to  a  line  formerly  indicated  by  the 
situation  of  the  lower  border  of  the  pectoralis  minor.  The 
midaxillary  and  subclavian  glands  may,  however,  be  infected. 
All  such  enlarged  glands  and  surrounding  fat  should  be  care- 
fully dissected  from  the  several  muscles,  and  to  do  this  best, 
the  fascia  covering  the  muscles  should  be  sacrificed.  In  fact, 
so  thorough  should  be  the  axillary  dissection  that  nothing  is 
left  on  its  inner  aspect  save  the  posterior  thoracic  or  nerve 
of  Bell;  on  the  posterior  aspect  only  the  long  subscapular 
nerve,  and  superiorly,  possibly  the  superior  thoracic  artery, 
if  it  arises  as  an  independent  branch  high  up  on  the  first  portion 
of  the  axillary.  In  such  circumstances  it  is  impossible,  in 
my  judgment,  to  reach  it  with  safety.  It  is  so  deeply  placed 
that  there  is  great  danger  of  doing  serious  damage  to  the  vein 
and  artery,  the  former  particularly,  if  an  attempt  is  made  to 
secure  the  vessel  at  its  root.  I  have  convinced  myself  by  work 
in  the  dissecting  room  that  it  is  at  least  a  hazardous  if  not  an 
unwarranted  procedure.  In  this  opinion  my  friend  Dr. 
Charles  W.  Bonney,  of  the  Anatomical  Staff  of  the  Jefferson 
Medical  College,  who  has  made  many  dissections  at  my  request, 
fully  concurs.  It  is  a  small  branch  and  negligible  so  far  as 
subsequent  hemorrhage  is  concerned.  Moreover,  it  not 
infrequently  arises  conjointly  with  the  acromio-thoracic,  and 
in  such  cases  is  easily  secured  with  the  other  vessel. 


Carcinoma.  291 

A  thorough  dissection  of  the  axilla  can  usually  be  finished 
in  twenty  minutes,  and  is  entirely  accomplished  through 
the  single  straight  incision.  It  should  invariably  be  from 
above  downward,  without  inward,  and  en  masse.  A  piece- 
meal extirpation  is  not  to  be  considered.  Patience,  a  good 
light,  and  working  with  blunt  dissectors,  all  insure  a  safe  and 
reasonably  speedy  dissection  of  the  axilla.  As  we  have  said, 
sharp  instruments  are  not  to  be  used  at  the  apex  of  the  axilla, 
but  may  materially  facilitate  the  dissection  at  its  base.  Acci- 
dental injuries  to  the  vein  are  not  common,  and  when  occurring, 
are,  if  practicable,  to  be  treated  by  lateral  ligature  or  suture. 
(Plate  XLVII.) 

The  advantages  accruing  from  attacking  the  axilla  before 
removing  the  breast  are  to  me  manifest  and  self-evident. 
In  the  first  place,  we  may  find,  as  S.  W.  Gross  taught  during 
my  internship  in  Jefferson  Hospital  ('79-80)  that  the  axilla 
may  be  so  extensively  involved  that  a  complete  eradication  of 
the  growth  is  impracticable  and  further  operative  steps  in- 
judicious. True  it  is,  however,  that  many  cases  which  Gross 
would  have  considered  inoperable,  can  be  successfully  dealt 
with  at  the  present  time,  because  of  the  more  thorough  axil- 
lary operation  since  division  of  the  muscles  became  a  routine 
procedure. 

Another  and  a  more  important  reason  (and  this  I  have 
insisted  upon  in  several  of  my  former  papers)  for  working 
from,  instead  of  toward,  the  axilla,  is  that  by  so  doing  we  avoid 
expressing  cancer  cells  into  adjacent,  even  possibly  remote 
tissues.  Therefore,  the  breast  should  not  be  handled,  massaged 
or  in  any  way  disturbed  until  the  axillary  dissection  has  been 
finished  and  the  completion  of  the  operation  is  near  at  hand. 
In  my  opinion,  this  is  one,  indeed  the  best  reason  for  not 
working  from  sternum  to  axilla,  and  for  reversing  the  technique 
of  Halsted  and  many  others. 

There  is  still  another  reason  for  making  the  axillary  dissec- 


292  Diseases  of  the  Breast. 

tion  the  first  instead  of  the  last  step  in  the  operation;  hemor- 
rhage is  certainly  very  much  less  when  the  vessels  are  ligated 
at  their  origin,  as  first  advised  and  practised  by  Willy  Meyer. 
Therefore,  the  time  of  the  operation  is  shortened  and  shock 
necessarily  minimized. 

It  is  of  interest  to  note  that  injuries  to  the  axillary  vein  were 
comparatively  frequent  and  serious  prior  to  the  time  when 
the  muscles  were  resected  and  an  aseptic  technique  was  rigidly 
observed.  I  personally  witnessed  three  such  accidents  in  the 
early  days  of  mammary  operations,  and  all  were  fatal  from 
sepsis.  I  have  never  wounded  the  vein  myself,  but  have 
deliberately  resected  it  three  times,  removing  in  one  instance 
at  least  four  inches  on  account  of  evident  infection  of  its  walls, 
as  it  passed  directly  through  a  large  mass  of  cancerous  glands. 
There  was  no  subsequent  edema  in  any  of  my  cases.  I  con- 
fess that  I  was  quite  apprehensive  the  first  time  I  was  compelled 
to  resect  the  vein,  as  I  was  not  then  advised  as  to  its  comparative 
safety.  Subsequently  I  had  reports  of  resections  in  24  cases 
in  the  practice  of  other  surgeons.  All  the  patients  recovered. 
In  only  four  of  them  was  there  resulting  edema  and  in  each 
of  these  it  was  both  slight  and  transient. 

While  accidental  injuries  to  the  vein,  when  practicable, 
should  be  treated  by  either  lateral  ligature  or  suture,  we  have 
shown  that  either  ligation  of  the  vein  in  continuity  or  its  resec- 
tion can  be  practised  with  comparative  safety. 

The  axillary  dissection  having  been  accomplished,  it  now 
remains  to  complete  the  skin  incision,  which  is  made  by 
beginning  at  the  middle  of  the  initial  incision  and  circum- 
scribing the  entire  breast  with  either  a  circular,  oval,  or  broadly 
elliptical  incision.  The  circular  incision  is  only  to  be  advised 
in  a  central  or  subareolar  growth.  Generally  I  employ  an  egg- 
shaped  incision  which  is  an  oval  so  broad  that  its  greater 
diameter  is  at  least  five  inches;  it  will  be  six  inches  or  more  if 
the  breast  is  a  large  one,  or  the  cancer  is  situated  peripherally, 


Carcinoma.  493 

for  the  skin  incision  must  under  no  circumstances  come  nearer 
than  two  inches  to  the  edge  of  the  growth.  (Plate  XLVIII.) 
The  knife  should  not  be  carried  straight  down  to  the  muscles 
beneath,  but  slanted  in  such  a  manner  as  to  divide  the  sub- 
cutaneous tissue  or  the  para-mammary  fat  at  least  two 
inches  further  out  than  the  skin  has  been  cut,  which  will 
practically  take  it  up  to  near  the  clavicle  superiorly,  well 
beyond  the  sternum  internally,  below  the  border  of  the 
great  pectoral  inferiorly,  or  well  on  to  the  external  oblique 
and  rectus. 

While  this  can  be  done  by  the  experienced  operator  by  a 
method  of  subcutaneous  transfixion,  using  for  the  purpose  a 
straight,  rather  long  and  sharp  pointed  knife,  I  prefer  to  use 
an  ordinary  scalpel,  the  skin  being  retracted  as  I  do  so  by  a 
careful  and  competent  assistant.  In  this  way  just  the  amount 
of  subcutaneous  tissue  may  be  left  adherent  to  the  skin  to  insure 
its  future  vitality.  Moreover^  I  prefer  to  ligate  at  once  any 
vessel  which  has  been  cut.  The  superior  thoracic,  if  not 
previously  secured  at  its  origin,  will  certainly  be  cut  in  under- 
mining superiorly  and  the  perforating  branches  of  the  internal 
mammary  of  the  opposite  side  may  be  severed  when  the  flap 
is  being  fashioned  internally.  I  have  seen  severe  hemorrhage, 
in  fact  an  unwarranted  amount  of  blood  lost  by  this  trans- 
fixion method,  the  removal  of  the  breast  being  completed  before 
any  vessels  were  tied. 

During  three  trips  to  Great  Britain  during  the  last  five 
years,  I  was  privileged  to  see  many  operations  for  mammary 
cancer,  and  was  impressed  with  the  facility  and  thoroughness 
with  which  undermining  is  practised  there.  The  British 
surgeons  excel  all  others  in  this  step  of  the  operation.  The 
late  Sir  Mitchell  Banks,  of  Liverpool,  Mr.  W.  Sampson  Handley, 
of  London,  and  Mr.  George  L.  Chiene,  of  Edinburgh  were 
particularly  deft  in  its  execution.  Such  extensive  under- 
mining of  the  skin  not  only  removes  any  outlving  or  rudimentary 


294  Diseases  of  the  Breast. 

portions  of  the  mammary  gland,  but  facilitates  the  removal 
of  the  fascia  covering  the  opposite  pectoral  muscle  internally, 
that  of  the  rectus  and  external  oblique  inferiorly,  and  that  of 
the  latissimus  dorsi  externally. 

Mr.  Handley,  of  London,  considers  this  step  of  the  operation 
one  of,  perhaps  the  most  important,  on  account  of  the  frequency 
with  which  invasion  of  the  peritoneal  cavity  occurs  as  the 
result  of  permeation  of  cancer  cells  along  the  fascial  planes 
of  the  muscles — the  rectus  particularly.  He,  therefore,  extends 
his  incision  downwards  in  the  direction  of  the  umbilicus,  so 
that  the  fascia  covering  the  rectus  may  be  removed  to  a  still 
greater  extent  than  has  been  my  practice.  Possibly  this  is 
wise,  and,  as  has  been  said  elsewhere,  I  am  inclined  to  adopt 
his  suggestion  in  the  future  and  to  still  further  extend  my 
wound  inferiorly  by  making  the  smaller  end  of  the  oval  some- 
what more  pointed.  I  do  not  agree  with  him,  however,  in 
thinking  that  the  removal  of  the  deep  fascia  is  far  more  to  be 
desired  than  the  free  removal  of  skin.  Quite  the  reverse. 
I  insist  first  and  foremost  that  we  should  begin  with  a  wide 
removal  of  skin,  and  in  deference  to  what  seems  to  be  sound 
logic  and  good  pathology,  am  willing  to  end  with  a  freer 
removal  of  the  deep  fascia  over  the  rectus.  My  dissections 
have  for  years  been  free. 

Undermining  also  insures  approximation  of  a  very  large 
wound.  The  breast  with  its  axillary  tail  still  attached,  the 
pectoral  muscles,  para-mammary  fat,  and  deep  fasciae,  are  all 
lifted  up  on  the  costal  wall,  as  shown  in  Plate  XLIX,  prelimin- 
ary to  cutting  the  costal  attachments  of  both  pectoralis  minor 
and  major.  In  cutting  the  attachments  of  the  great  pectoral 
muscle,  the  perforating  branches  of  the  internal  mammary 
will  be  severed,  and  should  be  promptly  seized  with  forceps. 
In  undermining  the  flap  internally,  the  perforating  branches 
of  the  opposite  side  may  be  cut  and  require  attention,  as  we 
have  already  said.     They  will  certainly  be  severed  in  dissecting 


Carcinoma.  295 

up  the  fascia  over  the  sternal  end  of  the  opposite  pectoral 
muscle  and  should  at  once  be  clamped  and  ligated. 

We  now  have  a  very  large  wound;  over  the  chest  the  inter- 
costal muscles  are  exposed ;  inf eriorly  the  external  oblique  and 
rectus;  posteriorly  the  latissimus  dorsi,  teres  major,  and  sub- 
scapularis,  and  the  long  subscapular  nerve ;  at  the  outer  aspect 
of  the  chest  (the  inner  aspect  of  the  axilla)  the  digitations  of 
the  serratus  magnus  and  the  nerve  of  Bell.     (Plate  L.) 

It  will  be  seen  from  Plate  L  that  a  part  of  the  pectoralis 
major  and  minor  muscles  is  left  at  their  origin.  This  is 
done  for  two  reasons:  It  prevents  adherence  of  the  skin  to 
the  ribs  and  makes  a  good  bed  to  plant  grafts  in  case  grafting 
is  necessary.  It  is  a  mistake  to  leave  the  ribs  bare  and  delays 
healing  of  the  wound. 

If  the  growth  is  situated  in  the  sternal  hemisphere  of  the 
gland,  the  oval  is  reversed,  so  that  its  smaller  end  is  at  the  axilla. 
By  so  doing  less  chance  is  taken  of  leaving  behind  infected  skin. 

In  case  the  tumor  is  situated  in  the  upper  hemisphere,  it 
is  my  invariable  custom  to  make  an  incision  above  the  clavicle 
and  to  carefully  explore  the  posterior  triangle  of  the  neck. 
It  should  extend  from  the  posterior  border  of  the  sternomastoid 
to  the  anterior  border  of  the  trapezius,  and  be  preceded  by  pull- 
ing the  skin  downwards  so  as  to  prevent  premature  injury  to 
the  external  jugular  vein.  I  prefer  to  make  a  separate  incision 
for  this  purpose  rather  than  to  extend  the  original  wound  into 
the  neck,  as  I  see  only  a  theoretic  reason  for  doing  this.  Little 
good  is  accomplished  by  it,  the  scar  made  is  unsightly  and  its 
subsequent  contraction  disadvantageous.  A  straight  incision 
on  the  clavicle  retracts  above  it  and  will  scarcely  be  noticed. 
Cutting  through  the  skin,  superficial  fascia,  platysma  and 
deep  fascia,  the  omohyoid  is  exposed,  held  upward  by  a  re- 
tractor, and  the  triangular  space  which  it  bounds  carefully 
freed  of  fat  and  enlarged  glands  if  any  be  present.  The  ex- 
ternal jugular  vein  is  usually  resected.     I  have  rarely  encount- 


296  Diseases  of  the  Breast. 

ered  supra-clavicular  involvement,  yet  believe  it  has  been 
demonstrated  that  this  step  of  the  operation  cannot  safely  be 
dispensed  with,  for  the  reason  previously  given,  viz.,  that  in 
malignant  growths  situated  in  the  upper  and  peripheral  portions 
of  the  breast,  a  chain  of  lymphatic  vessels  passes  from  the  breast 
over  the  clavicle  to  empty  into  glands  in  the  posterior  cervical 
triangle. 

In  tumors  of  the  lower  hemisphere,  I  never  explore  the  neck. 
The  supra-clavicular  incision  is  also  made  in  case  I  encounter 
infection  of  the  glands  or  fat  in  Mohrenheim's  space.  If  the 
glands  just  below  the  clavicle  are  involved,  it  is  reasonable  to 
infer  that  those  just  above  it  may  be  infected;  at  least  it  is 
unwise  to  infer  that  they  are  not.  I  have  not  found  exploring 
the  neck  to  add  materially  to  the  shock  or  danger  of  the  opera- 
tion and,  moreover,  I  am  convinced  that  now  and  then  a 
case  is  saved  by  taking  this  additional  precaution.  I  have 
never,  however,  divided  the  clavicle  nor  do  I  believe  it  neces- 
sary; neither  do  I  feel  that  this  step  of  the  operation  should 
contemplate  removing  a  portion  of  the  subclavius  muscle  or 
forcing  a  mass  from  the  neck  to  the  chest  behind  the  clavicle, 
as  such  manipulations  may  express  cancer  cells  in  the  event  of 
cervical  infection.  Such  dissections  may  undoubtedly  be 
done  with  relative  safety  by  the  patient  and  skillful  operator, 
but  after  all  do  not  result  in  an  amount  of  good  to  justify  the 
risk — immediate  and  potential — inherent  in  them. 

Axvy  slight  or  extensive  oozing  can  be  quickly  stanched  by 
the  application  of  hot  water  at  a  temperature  of  1200.  I  not 
only  consider  this  the  best  hemostatic,  but  feel  that  it  is  ad- 
vantageous in  the  event  that  our  manipulations  may  have 
expressed  cancer  cells  on  any  part  of  the  wound.  Therefore, 
freely  douching  the  part,  whether  it  is  bleeding  or  not,  is 
desirable.  Any  vessel  of  sufficient  size  to  require  a  ligature  is  tied 
with  fine  Pagenstecher ;  others  are  twisted.  Complete  hemos- 
tasis  is  insisted  upon.     It  is  surprising  how  few  ligatures  will 


Carcinoma.  297 

be  necessary  if  the  large  branches  already  mentioned  have 
been  ligated  at  their  origin.  I  consider  it  important  to 
thoroughly  arrest  hemorrhage  before  beginning  the  suturing, 
for  at  the  best  we  must  expect  a  considerable  amount  of  serum 
to  be  poured  out  into  such  a  large  wound. 

Closure  of  the  wound  is  begun  where  it  was  started — that  is, 
near  the  clavicle,  and  can  be  accomplished  by  either  inter- 
rupted or  continuous  sutures.  I  prefer  several  interrupted 
Pagenstecher  sutures,  which  give  the  necessary  support  and 
act  as  stays,  and  for  accurate  approximation,  where  the 
tension  is  not  too  great,  supplement  them  with  a  continued 
suture  of  horsehair  after  the  buttonhole  method.  In  the 
event  of  much  tension,  interrupted  sutures  are  used  throughout. 

The  first  incision  having  been  sutured,  closure  of  the  oval  or 
circular  (whichever  has  been  employed)  portion  of  the  wound 
is  begun  at  the  sternal  end.  When  we  have  advanced  one- 
third  of  the  distance  between  the  two  extremes  of  the  second 
and  larger  incision,  it  will  be  easy  to  tell  whether  or  not  approx- 
imation of  the  flaps  can  be  accomplished  with  facility;  if  not, 
the  suturing  should  be  stopped  at  this  point,  begun  at  the  other 
end,  and  carried  out  to  the  extent  of  one-third  of  the  incision; 
the  central  third  of  the  wound  is  left  unsutured  and  is  im- 
mediately covered  by  suitable  grafts  taken  from  the  thigh 
after  the  method  of  Thiersch.  It  has  been  rarely  necessary 
for  me  to  graft  of  late,  for  even  though  a  very  large  wound  is 
made,  the  extensive  undermining  makes  approximation  easy. 
(Plate  LI.)  The  length  of  the  horizontal  suture  line  is  twelve 
inches  or  more.     I  have  never  found  it  less. 

A  vast  majority  of  surgeons  employ  drainage.  I  have  nearly 
always  done  so  and  still  believe  it  to  be  best  in  the  majority 
of  instances.  A  tube  is  inserted  at  either  angle  of  the  wound; 
one  posteriorly  to  drain  the  axilla,  the  other  anteriorly  extend- 
ing down  between  the  costal  margin  and  umbilicus.  I  do 
not  question  that  such  a  wound  may  be  safely  closed  in  many 


298  Diseases  of  the  Breast. 

cases  without  drainage  and  occasionally  have  done  so  without 
cause  for  regret.  If,  however,  the  breast  is  large,  or  the  work 
in  the  axilla  has  been  unusually  prolonged  on  account  of  exten- 
sive axillary  involvement,  requiring  a  difficult  and  tedious- 
dissection,  I  think  it  safer  to  drain.  I  find  that  the  custom 
of  draining  such  wounds  is  practically  universal  among  Amer- 
ican surgeons.  Only  three  of  a  large  number  of  surgeons  com- 
municated with  do  not  employ  drainage. 

An  abundant  dressing  of  aseptic  gauze  is  now  applied  in 
such  a  way  as  to  obliterate  the  axillary  space.  A  wedge-shaped 
pad  is  placed  between  the  arm  and  chest  and  the  arm  bound 
firmly  to  the  side  by  broad  adhesive  straps  for  at  least  24  hours. 
I  see  no  advantage  in  applying  the  dressings  so  that  the  arm 
will  be  at  a  right  angle  to  the  body.  Tension  upon  the  flaps 
is  increased  by  such  a  position,  hemostasis  is  certainly  not 
favored  by  it,  and  the  axillary  space  is  made  to  gap,  thereby 
inviting  a  subsequent  collection  of  serum  which  may  give 
trouble.  At  the  end  of  24  hours  the  arm  is  released,  and,  if 
painful,  rubbed  with  alcohol.  It  is  not  included  in  the  sub- 
sequent dressing. 

If  we  now  examine  the  specimen,  it  will  be  seen  that  the 
para-mammary  fat  has  been  removed  to  a  very  much  greater 
extent  than  has  hitherto  been  usual  in  breast  operations. 
In  fact  so  much  has  been  taken  away  that  there  are  two  circles 
or  ovals;  one,  represented  by  the  skin  itself,  which  is  five  or 
more  inches  in  diameter;  another,  and  very  much  larger  circle 
or  oval,  by  the  fat  and  deep  fascia.  In  other  words,  perhaps 
double  the  extent  of  the  skin  removed. 

Plate  LII  shows  the  outline  of  the  incisions  and  the  line  of 
the  cicatrix. 

The  assistant  holding  the  arm  should  be  careful  lest  hyper- 
extension  be  made  at  any  time  during  the  operation.  This 
can  easily  be  done  after  the  pectoral  muscles  are  cut  and  may 
possibly  result  in  monoplegia.     At  least  this  has  been  con- 


PLATE  XLIII  A. 


PLATE  XLIV. 


PLATE  XLV. 


PLATE  XLVI. 


PLATE  XLVII. 


PLATE  XLVIII. 


PLATE  XLIX. 


PLATE  L. 


PLATE  LI. 


PLATE  LII. 


O     (H     D 

5  y  a 
■g-9  M 

C   <2  Es 

^3  3 


to 


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c  •£  o 
2-° 


Carcinoma.  319 

sidered  to  be  the  cause  of  such  paralysis  after  breast  operations. 
I  have  never  known  it  to  occur  in  any  of  my  cases.  Still, 
this  accident  has  been  reported  sufficiently  often  to  warrant 
explicit  instructions  being  given  to  the  assistant  before 
the  operation  is  begun.  In  my  judgment,  monoplegia  follow- 
ing such  operations  is  more  likely  to  result  from  pressure  on 
the  limb  posteriorly,  injury  being  caused  to  the  musculo-spiral 
nerve.  I  have  known  this  to  happen  once  or  twice,  but  never 
in  a  breast  operation,  and  it  has  always  been  due  apparently 
to  the  pressure  resulting  from  the  arm  resting  upon  or  hanging 
over  the  sharp  edge  of  the  operating  table. 

Post-operative  Treatment. — The  patients  usually  feel  well 
enough  to  sit  up  on  the  third  day.  I  generally  allow  them 
to  do  so  in  bed  and  have  occasionally  permitted  those  doing 
best  to  sit  in  a  chair  for  a  part  of  the  morning  and  afternoon. 
I  prefer,  however,  to  keep  them  in  bed  until  the  fifth  day. 
One  of  my  patients  left  the  hospital  on  the  sixth  day,  going 
to  her  home  in  an  adjoining  state.  She  felt  perfectly  well 
and  able  for  the  journey.  I  do  not  think  that  I  would  have 
countenanced  her  leaving  the  hospital  so  soon  had  the  weather 
not  been  very  hot  and  her  home  far  more  comfortable  than 
the  hospital. 

My  patients  often  leave  the  hospital  in  ten  days  or  as  soon 
as  the  sutures  are  removed.  Some  remain  a  fortnight;  ex- 
ceptionally two  and  a  half  or  three  weeks  may  be  required  if 
either  skin  grafting  has  been  necessary  or  a  part  of  the  wound 
has  been  allowed  to  granulate. 

The  drainage  tubes  are  removed  at  the  change  of  dressings 
at  the  end  of  twenty-four  hours.  They  are  inserted,  as  for- 
merly stated,  at  either  angle  of  my  wound;  one  posteriorly  to 
drain  the  axillary  space;  the  other  anteriorly  which  extends 
well  down  to  midway  between  the  costal  margin  and  the  um- 
bilicus as  serum  is  likely  to  accumulate  here.  I  formerly  made 
a  posterior  stab  and  inserted  a  drainage  tube  into  the  axilla  only. 


320  Diseases  of  the   Breast. 

I  ignore  all  suggestions  which  have  been  made  to  keep  the 
arm  in  this  or  that  position  so  as  to  increase  its  future  usefulness. 
Some  believe  moderate  abduction  is  necessary;  others  think 
that  the  arm  should  be  at  a  right  angle  to  the  body;  others 
still  that  a  triangular  splint  should  be  used.  All  such  sug- 
gestions and  devices  have  been  thought  necessary  on  account 
of  a  definite  restriction  in  the  movements  of  the  arm  after 
certain  operative  procedures,  where  the  cicatrix  extends  from 
the  chest  wall  to  the  arm,  and  necessarily  fetters  it  subse- 
quently more  or  less.  A  very  great  majority  of  such  incisions 
do  cause  subsequent  trouble  with  the  arm  and,  therefore,  the 
numerous  suggestions  and  expedients  for  preventing  it  and  for 
mobilizing  the  scar. 

The  cicatrix  following  the  operation  I  employ  is  entirely 
on  the  chest  wall,  does  not  extend  to  the  arm,  or  in  any  way 
encroach  upon  the  axilla;]  therefore,  its  "mobilization"  is 
entirely  a  negligible  quantity.  I  release  the  arm  on  the  second 
day  or  when  the  drainage  tubes  are  removed  and  the  dressings 
changed.  Subsequently  the  patient  is  allowed  to  move  it  at 
will. 

Another  serious  objection  which  I  have  found  to  the  incisions 
which  pass  from  chest  to  arm,  or  the  reverse,  is  that  the  cicatrix 
has  occasionally  been  responsible  for  a  subsequent  edema  of 
the  arm. 

I  no  longer  have  my  patients  complain  of  not  being  able  to 
dress  their  back  hair,  or  indeed  anything  that  they  were  able 
to  do  before  the  operation.  I  do  not  see  the  slightest  differ- 
ence in  the  relative  usefulness  of  the  two  arms.  I  have  had 
quite  a  number  of  my  patients  complain  of  limitations  in  the 
movements  of  the  arm  when  I  employed  Warren's  operation. 
In  two  cases,  the  bridge  of  skin  from  arm  to  thorax  was  so 
pronounced  that  I  subsequently,  months  after  the  operation, 
divided  it,  releasing  the  arm,  and  also  lessening  the  pain 
caused  bv  the  contraction  of  the  scar.     In  a  third  and  more 


Carcinoma.  ->2i 

marked  example  of  the  kind,  I  wanted  very  much  to  do  it, 
but  the  patient  would  not  permit  me. 

I  wish  to  say  definitely  that  any  limitation  in  the  movement 
of  the  arm  is  not  due  to  the  loss  of  the  pectoral  muscles, 
strange  as  it  may  seem,  but  in  every  case  that  I  have  seen  is 
entirely  due  to  a  cicatrix  following  an  incision  unfortunately 
placed. 

I  have  two  patients  in  whom  both  breasts  have  been  operated 
on;  one  of  them  had  the  right  breast  removed  five  years  ago 
for  a  scirrhus  carcinoma  with  more  than  an  average  amount 
of  axillary  involvement.     A  very  large  wound  was  made  after 
the  method  then  employed  by  Prof.  Warren,  differing  a  little, 
but  not  essentially  from  the  method  which  he  now  uses.     Both 
muscles  were  sacrificed.     Two  years  later  a  cyst  appeared  in  . 
the  left  breast.     She  being  nearly  fifty,  having  had  cancer  in  the 
opposite  breast  two  years  previously  and  her  mother  having 
died   of    mammary  carcinoma,    I   deemed   it   wise,    and   she 
requested  me  to  remove  the  entire  mamma.     This  was  done 
and  the  fascia  covering  the  great  pectoral  muscle  removed 
also.     I  did  not,  however,  sacrifice  the  muscles  themselves. 
At  the  same  time  that  the  operation  was  performed  on  the  left 
breast  a  bridge  of  skin  which  had  fettered  the  right  arm  and 
had  prevented  her  from  "doing  her  back  hair,"  also  causing  a 
moderate  edema  of  the  limb,  was  cut  and  considerable  of  the 
cicatrix    excised.     The    resulting   defect    was    covered    by   a 
Thiersch  graft  so  as  to  prevent  subsequent  contraction.     To- 
day she  has  a  supple  cicatrix,  the  edema  has  entirely  passed 
away,  and  she  uses  her  arm  as  well  as  she  ever  did;  just  as 
well  as  she  does  the  left  arm,  notwithstanding  that  the  muscles 
were  sacrificed  on  the  right  side  and  spared  on  the  left. 

I  may  state  that  this  patient  has  been  in  my  office  within 
a  week.  Therefore,  I  speak  advisedly  both  as  to  the  local  and 
general  condition.  She  was  never  in  better  health  in  her  life. 
The  supra-clavicular  operation  was  done  in  this  case,  but  was 


322  Diseases  of  the   Breast. 

found  to  have  been  unnecessary,  as  there  was  no  infection  above 
the  clavicle. 

It  has  been  my  experience  to  see  four  cases  of  pneumonia 
following  breast  operations.  Fortunately  all  have  recovered. 
Three  of  them  came  early,  within  72  hours  after  the  anesthetic, 
and  were  presumably  due  to  the  ether,  as  they  were  catarrhal 
pneumonias. 

The  last  case  I  encountered  two  years  ago  when  a  patient 
doing  splendidly  up  to  the  eleventh  day,  being  about  ready  to 
go  home,  slept  in  a  draft,  and  had  an  acute,  frank  lobar 
pneumonia,  which  delayed  her  convalescence  several  weeks. 
It  was  followed  by  phlegmasia  in  both  limbs.  This  is  the  only 
time  I  have  ever  seen  phlebitis  following  a  breast  operation. 
The  patient  made  a  complete  recovery. 

The  right  breast  was  removed;  the  pneumonia  was  clearly 
confined  to  the  left  lung.  The  phlebitis  began  in  the  left  leg 
about  the  time  the  pneumonia  was  subsiding;  the  right  leg  be- 
came involved  a  few  days  later,  and  both  limbs  had  to  be 
bandaged  for  some  weeks  afterwards.  In  time,  however,  the 
return  to  their  normal  condition  was  complete. 

There  has  been  no  recurrence  of  the  malignant  disease,  and 
the  patient  is  to-day  in  the  very  best  possible  health — much 
better,  she  states,  than  she  has  ever  been  before. 

Plastic  Operations. — Various  plastic  procedures  have  been 
devised  to  fill  in  the  defect  caused  by  the  extensive  removal 
of  the  superficial  structures  in  the  complete  operation  for  the 
removal  of  a  carcinomatous  breast.  Chief  among  the  earlier 
of  these  procedures  may  be  mentioned  the  methods  practised 
by  Legueu  and  Graeve  in  France  and  Sweden  respectively, 
by  Mixter  in  this  country,  and  by  Franke  in  Germany. 

In  order  to  cover  in  a  defect  caused  by  the  ablation  of  an 
extensive  recurrent  carcinoma  extending  from  the  axillary 
line  to  the  sternum,  Legueu  made  a  large  flap  containing 
the  other  breast  and  sutured  it  over  the  raw  surface  made  bv  his 


Carcinoma.  323 

extensive  dissection,  thus  transplanting  the  healthy  breast. 
Graeve  and  Mixter  performed  similar  operations  for  the  same 
purpose.  Franke's  procedure  differed  from  these  in  that  he 
dissected  out  the  healthy  breast  from  the  flap  which  he  cut, 
using  only  the  skin  and  subcutaneous  tissues,  thereby  doing 
away  with  the  unsightliness  of  a  single  breast  in  the  middle  of 
the  anterior  thoracic  wall. 

Of  the  plastic  procedures  popular  in  America,  I  consider 
that  of  J.  Collins  Warren  the  best,  for  this  method  is  with- 
out the  inherent  danger  of  all  other  plastic  procedures,  inas- 
much as  the  skin  is  widely  removed,  the  defect  resulting  there- 
from is  covered  by  a  cutaneous  flap  brought  from  below,  a 
region  which,  in  a  majority  of  instances,  will  be  farthest  re- 
moved from  the  tumor,  and,  therefore,  presumably  healthy. 
In  other  words,  the  flap  is  cut  last,  and  only  to  facilitate  the 
closure  of  a  wound  sufficiently  ample.  I  have  employed  this 
method  frequently  and  with  satisfactory  results  in  the  main. 
The  one  objection  that  I  have  sometimes  found  with  it  has  been 
a  resulting  band  of  skin  which  subsequently  fetters  the  arm 
somewhat  in  its  movements  and  less  frequently  causes  edema 
on  account  of  the  incision  extending  from  the  chest  to  the  hu- 
meral attachment  of  the  pectoralis  major. 

Warren's  operation  is  described  by  its  originator  practically 
as  follows : 

"An  incision  is  made  from  the  anterior  and  outer  margin  of 
the  axilla  running  a  little  above  its  upper  border  and  the  line 
of  insertion  of  the  pectoralis  major  muscle  around  the  lower 
border  of  the  breast  to  a  point  on  the  boundary  line  of  the  inner 
and  lower  quadrant.  A  second  incision  is  made,  beginning  at 
the  middle  of  the  anterior  axillary  fold,  gradually  diverging 
from  the  first  incision  as  it  approaches  the  breast  and,  sweeping 
around  the  upper  and  inner  margin  of  the  organ,  meets  the 
first  incision  at  its  terminal  point. 

"A  flap  is  next  marked  out  on  the  outer  side  of  the  pectoral 


324  Diseases  of  the  Breast. 

region  by  dividing  the  skin  on  the  outer  edge  of  the  wound,  on 
a  line  drawn  first  at  right  angles  to  the  primary  incision  and 
then  gradually  sweeping  around  until  it  becomes  parallel  to  it 
and  terminates  at  a  point  a  little  below  the  level  of  the  lower 
margin  of  the  wound.     (Plate  LIU.) 

"  In  case  there  is  infection  of  the  cervical  region,  an  additional 
incision  should  be  made  from  the  middle  of  the  upper  half  of 
incision  number  two  along  the  posterior  border  of  the  sterno- 
mastoid  muscle  to  expose  the  clavicle  and  the  posterior  cervical 
triangle.  This  incision,  if  necessary,  should  not  be  made  until 
a  later  stage  of  the  operation. 

"The  second  step  of  the  operation  is  the  dissection  of  the  in- 
teguments freely  on  all  sides,  the  axilla  included,  from  the  sub- 
jacent adipose  tissue.  The  axillary  skin  and  the  flap  are  thus 
dissected  off  on  the  outer  and  lower  side  of  the  wound,  and  the 
dissection  on  the  median  line  is  carried  well  over  the  margin  of 
the  sternum.  This  superficial  dissection  should  also  be  carried 
upwards  so  as  to  expose  the  clavicle.     (Plate  LIV.) 

"The  third  stage  of  the  operation  is  now  begun.  Beginning 
with  the  humeral  insertion  of  the  pectoralis  major  muscle, 
the  forefinger  of  the  left  hand  of  the  operator  is  slipped  under 
the  edge  of  the  muscle  from  above  downward  and  the  muscle 
is  divided  a  short  distance  from  its  insertion.  (Plate  LV.) 
The  proximal  end  of  the  muscle  is  seized  with  hooks  and  pulled 
in  the  direction  of  its  origin,  while  its  fibers  are  separated  from 
those  in  immediate  contact  with  the  clavicle.  An  assistant 
while  holding  the  hooks  gently  draws  the  breast  with  the  other 
hand  in  the  direction  of  the  epigastrium.  A  few  touches  with 
the  point  of  the  knife  expose  the  insertion  of  the  pectoralis 
minor  muscle.  The  finger  is  now  hooked  under  this  insertion 
and  the  muscle  divided  (Plate  LVI). 

"When  the  assistant  retracts  the  breast  in  the  direction  already 
indicated,  the  axillary  region  is  freely  exposed,  and  the  thin 
fascia  overlying  the  vessels  being  divided,  the  larger  vessels 


Carcinoma. 


325 


are  readily  identified.  In  this  way  the  dissection  of  the  axilla 
can  be  carried  out  with  great  precision,  and  the  origin  of  all 
the  large  branches  can  be  secured  with  a  ligature  (Plate  LVII). 

"As  the  dissection  of  the  axilla  approaches  the  clavicle,  care 
must  be  taken  not  to  cut  through  the  superjacent  fat  that  has 
been  exposed  by  the  earlier  dissection,  but  to  reflect  it  back 
in  every  direction  toward  the  center  of  the  mass  so  that  the 
upper  edge  of  the  origin  of  the  pectoralis  major  at  the  sternal 
margin  is  clearly  identified.  As  the  dissection  proceeds  down- 
ward and  outward  in  the  axilla,  the  adipose  tissue  must  not 
be  divided  until  the  knife  can  come  down  upon  the  latissimus 
dorsi  muscle.  The  greatest  care  must  be  taken  not  to  separate 
any  of  the  tissues  from  the  included  lymphatic  glands  or  to  cut 
into  them. 

"A  few  sweeps  of  the  knife  separate  the  mass  from  the  latis- 
simus dorsi  muscle.  The  breast  is  now  seized  by  the  operator 
and  rapidly  dissected  off  the  thoracic  wall  from  without  in- 
ward. The  origin  of  the  pectoralis  minor  is  first  divided,  and 
the  final  act  of  the  operation  consists  in  severing  the  origin  of 
the  pectoralis  major  while  the  breast  and  attached  tissue  are 
firmly  held  away  from  the  sternal  margin.     (Plate  LVIII.) 

"If  deemed  advisable  to  invade  the  neck,  the  incision  already 
mentioned  is  made  along  the  posterior  border  of  the  sterno- 
mastoid  muscle.  After  cutting  through  the  deep  layer  of 
the  superficial  fascia  of  the  neck,  the  posterior  border  of  the 
sternomastoid  is  pulled  inward  and  the  omohyoid  is  lifted  up- 
ward. A  thin  fascia  then  presents  itself,  under  which  lies  a 
pad  of  adipose  tissue,  in  which  one  or  more  lymphatic  glands 
are  found.  When  the  region  has  been  properly  cleaned  out, 
it  is  possible  to  make  the  forefingers  of  each  hand  come  in 
contact  with  one  another  beneath  the  clavicle. 

"The  closure  of  the  wound  in  this  operation  has  always 
been  a  difficult  problem,  since  it  has  been  decided  that  the 
whole  integument  of  the  breast  should  be  included  between 


326  Diseases  of  the  Breast. 

the  incisions.  Any  method  which  permits  of  an  easy  approx- 
imation of  the  edges  of  the  wound  is  out  of  date.  The  lower 
portion  of  the  wound  is  the  part  where  the  edges  are  the  most 
difficult  to  approximate.  The  free  loosening  up  of  the  skin 
enables  the  upper  portions  to  come  easily  together. 

"The  flap  made  at  the  outer  side  of  the  wound  is  about  the 
size  of  the  human  hand,  and  when  first  turned  in  seems  to  be 
totally  inadequate  for  the  purpose.  To  draw  upon  this  flap 
is  to  endanger  its  vitality.  Therefore,  the  suturing  is  begun  on 
the  outskirts  of  the  wound  at  four  different  points,  viz.,  at 
each  end  and  on  each  side.  A  few  stitches  are  taken  at  the 
axillary  and  at  the  sternal  ends  of  the  wound  first.  The  flap 
is  then  turned  in  and  held  in  place  by  a  temporary  stitch,  while 
it  is  gradually  pushed  up  into  place  from  below  by  sutures  firmly 
girding  together  the  edges  of  the  skin  to  which  the  flap  was 
originally  attached.  Sutures  should  all  be  superficial,  as  deep 
sutures  cut  and  do  not  give  the  skin  included  by  them  a  chance 
to  stretch.     Plate  LIX  shows  the  wound  as  finally  closed."* 

The  margins  of  such  an  extensive  wound  cannot  be  approxi- 
mated, and  for  the  purpose  of  covering  it  in,  a  flap  is  taken  from 
the  side  of  the  thorax  and  turned  up  from  the  lower  margin  of 
the  wound.  An  incision  is  made  at  the  middle  of  the  lower 
lip  and  at  right  angles  to  it.  The  knife  is  carried  in  a  gentle 
curve  downward  or  upward  as  preferred,  or  in  both  directions, 
and  the  flap  or  flaps  can  be  so  spread  out  as  to  cover  in  the 
greater  portion,  if  not  all,  of  the  exposed  surface. 

In  the  procedure  recently  devised  by  Jabez  N.  Jackson,  of 
Kansas  City,  Missouri,  the  skin  incision  is  begun  at  a  point 
about  one  and  one-half  inches  below  the  clavicle  in  the  sulcus 
between  the  deltoid  and  pectoralis  major  muscles.  From  this 
point  the  incision  is  carried  in  a  straight  line  along  the  sulcus, 
parallel  to  the  .inner  border  of  the  deltoid  muscle,  until  it 
reaches  the  lower  border  of  the  pectoral  fold  as  it  terminates  in 

*  Annals  of  Surgery,  December,  1904. 


PLATE  LIII. 


Showing  skin  incisions  in  Warren's  operation.     {Annals  of  Surgery.) 


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Showing  appearance  of  wound  jafter  closure  in  Warren's  operation. 
(Slightly  modified  owing  to  an  unusually  large  wound.) 


Carcinoma.  341 

the  arm.  As  this  incision  is  carried  down  through  the  skin  and 
superficial  fascia,  it  exposes  the  fibers  of  the  pectoralis  major 
converging  well  to  its  tendinous  insertion  on  the  humerus. 
At  the  lower  point  of  this  incision,  where  it  curves  along  the 
under  border  of  the  pectoralis  major,  the  index  finger  is  now 
shoved  up  underneath  the  pectoralis  major  muscle  and  brought 
out  again  at  its  upper  border,  so  that  the  entire  muscle  is  thus 
hooked  up  on  the  index  finger  and  by  blunt  dissection  separated 
out  to  its  tendinous  insertion.  The  tendon  of  the  muscle  is 
then  divided  close  to  its  insertion  into  the  humerus.  The 
muscle  immediately  retracts  toward  the  chest  and  exposes, 
underneath,  the  pectoralis  minor  muscle  imbedded  in  its  fascia, 
which  above  runs  to  the  clavicle,  and  below  spreads  out  over 
the  chest  wall.  It  is  also  divided  close  to  its  insertion,  and, 
like  the  pectoralis  major,  retracts  at  once,  thus  giving  a  good 
exposure  of  the  axillary  space.  If  necessary  the  horizontal  in- 
cision may  be  begun  before  the  axilla  is  cleared  out. 

After  the  dissection  of  the  axilla  has  been  finished,  the  orig- 
inal skin  incision  is  completed  by  carrying  the  horizontal  in- 
cision over  to  the  chest  and  outlining  the  outer  half  of  the  ellipse, 
which  should  parallel  the  original  incision  so  as  to  permit  the 
flap  to  be  raised  and  turned  upward  toward  the  clavicle,  thus 
giving  a  deeper  exposure  of  the  attachments  of  the  pectoral 
muscle  above  and  in  front.  It  is  important  that  a  small  tenac- 
ulum forceps  should  be  placed  at  each  angle  of  this  flap  when 
it  is  completed;  it  is  then  wrapped  in  gauze  until  it  is  used 
later  to  cover  in  the  defect.  The  dissection  is  now  completed 
usually  with  gauze,  the  tissues  are  loosened  up  underneath  the 
pectoral  muscles  under  the  breast  and  toward  the  chest,  and 
the  remaining  attachments  of  the  muscles  separated.  After 
the  pectoralis  major  muscle  has  been  entirely  separated  from 
beneath,  the  breast  is  allowed  to  drop  back  into  its  normal 
position,  the  skin  incision  is  completed  and  the  breast  and 
pectoral  muscles  are  finally  removed. 


342  Diseases  of  the   Breast. 

The  quadrilateral  flap  of  skin  and  superficial  fascia  which 
originally  formed  the  anterior  covering  of  the  axilla  is  now 
stretched  out  by  tenaculum  forceps  and  transferred  inward  to 
cover  the  defect  of  the  chest  wall  created  by  the  removal  of  the 
skin  of  the  breast  about  the  nipple.  This  flap,  which  is  one  of 
the  distinctive  features  of  the  operation,  will  always  contract 
after  it  has  been  loosened  and  will  look  as  though  it  could  be 
of  but  little  service.  It  is  spread  out  by  means  of  the  tenaculum 
forceps  already  mentioned,  with  probably  another  pair  on 
either  side.  As  the  flap  is  drawn  over  on  the  chest  it  is  fixed 
by  attachment  to  the  corresponding  skin  margin,  as  shown  in 
Plates  LXVI  and  LXVIL  Another  distinctive  point  consists 
in  catching  up,  with  the  tenaculum,  the  margin  of  the  lower  por- 
tion of  the  pectoral  fold,  which  represents  the  integument  which 
formed  the  original  floor  of  the  axilla  and  which  in  thin  subjects 
is  often  very  marked.  The  tenaculum  on  this  margin  is  placed 
at  such  a  distance  from  the  lowest  point  of  the  first  vertical  line 
that  when  drawn  upward  it  will  bring  this  skin  point  up  to  the 
beginning  of  the  first  incision  beneath  the  clavicle.  This  man- 
euver brings  the  loose  skin  from  the  floor  of  the  axilla  close 
around  the  axillary  vessels  and  does  away  entirely  with  the 
axilla  as  a  cavity.  These  tenacula  are  usually  clamped  and 
mark  the  fixed  points  of  coaptation. 

An  approximation  suture  of  silk-worm  gut  is  now  placed 
at  these  points  to  steady  the  subsequent  suturing.  The  re- 
maining portion  of  the  incision  may  be  closed  either  with  inter- 
rupted or  continuous  sutures.  A  puncture  in  the  lowest  re- 
cesses of  the  wound  space  behind  furnishes  opportunity  for  a 
drainage  tube. 

The  steps  of  this  operation  are  shown  in  Plates  LX  to 
LXVIII  inclusive. 

I  have  employed  this  procedure  in  a  reasonable  number  of 
cases  and  consider  that  it  meets  most  of  the  requirements  ad- 
mirably.    The  chief  defect  with  it,  a  most  serious  one  as  I 


PLATE  LX. 


Outline  of  skin  incision  complete,  showing  formation  of  first  flap. 
(Jabez  N.  Jackson.) 


PLATE  LXI. 


PLATE  LXII. 


PLATE  LXIII. 


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Carcinoma.  361 

see  it,  is  that  the  skin  flap  is  taken  from  a  region  near  to,  if 
not  actually  where  the  growth  is  situated — in  the  greater  num- 
ber of  cases — the  axillary  hemisphere.  It  insures  easy  closure 
of  the  wound,  but  at  the  expense  of  retaining  suspicious  if  not 
certainly  infected  skin.  Within  the  past  year  I  employed  this 
incision  to  my  great  regret  in  two  cases  certainly,  as  both  were 
reoperated  for  recurrences  in  the  skin  within  six  months  after 
operation.  In  one  of  them  the  tumor  was  situated  at  the 
sternal  end  of  the  breast,  which  made  the  recurrence  all  the  more 
unlooked  for  and  disappointing.  In  other  cases  where  the 
growths  were  situated  inferiorly  and  jar  away  from  the  flap,  I 
have  not,  as  yet,  encountered  recurrences. 

Another  defect  is  that  the  skin  overlying  the  entire  breast  is 
not  sacrificed.  This  can,  however,  be  overcome  by  broadening 
the  ellipse  and  extending  its  inner  half  well  to  or  beyond  the 
middle  line  of  the  sternum.  This  must  be  done  to  be  safe  for  tu- 
mors in  the  sternal  half  of  the  gland.  Moreover,  such  a  modifica- 
tion would  permit  of  a  freer  removal  of  the  deep  fascia,  which 
has  recently  been  insisted  upon  as  a  pathological  necessity. 
This  operation  is  ingenious,  original,  and  can  be  quickly  done, 
but  if  more  skin  were  removed,  it  would  still  permit  of  primary 
union,  and  be  followed  by  better  ultimate  results. 

In  a  communication]  recently  received  from  Dr.  Jack- 
son, he  states  that  the  illustrations  of  his  operation  do  not 
exactly  represent  the  technique  which  he  now  employs.  He 
states  that  he  "sacrifices  practically  the  entire  skin  of  the  breast, 
or  at  least  all  lying  within  a  radius  of  three  or  four  inches  be- 
yond the  furthest  extension  of  the  tumor  mass."  With  this 
modification  I  should  think  more  favorably  of  his  procedure. 

Dawbarn,  of  New  York,  has  suggested  an  ingenious  operation 
to  supply  the  defect  caused  by  the  removal  of  the  pectoralis 
major  muscle.  He  transplants  a  part  of  the  deltoid,  having 
its  origin  at  the  outer  half  of  the  clavicle,  attaching  it  to  the 
severed  pectoralis  major  which  is  attached  to  the  inner  half  of 


362  Diseases  of  the  Breast. 

the  bone.  In  a  personal  communication  to  me  he  describes 
his  operation  as  follows  (it  has  not  yet  been  published): 
"After  both  pectoral  muscles  have  been  removed  our  patients 
have  no  other  means  than  the  action  of  the  anterior  fibers 
of  the  deltoid  for  the  advancement  of  the  arm  nor  for  its  ad- 
duction. When  one  considers  the  point  of  origin  of  this  por- 
tion of  the  deltoid,  it  is  at  once  obvious  that  if  this  part  of  the 
muscle  sprang  from  the  inner  rather  than  the  outer  half  of  the 
clavicle  its  power  to  produce  such  motions  would  be  greatly 
increased.  Bearing  this  in  mind,  I  have  for  several  years  past 
quite  regularly  adopted  a  plan  of  muscle  anastomosis,  viz., 
the  detachment  from  its  origin  of  an  inch  (more  if  thought 
necessary)  of  the  anterior  fibers  of  the  deltoid,  the  muscle 
being  split  in  a  direction  parallel  to  its  long  axis  for  a  distance 
quite  short  but  sufficient  to  permit  the  detached  portion  to  be 
sutured  to  a  stump,  of  corresponding  size,  of  the  adjacent  pec- 
toralis  major.  This  resource  is  of  course  contraindicated  if 
the  cancer  extends  to  the  vicinity  of  the  muscles  involved  in 
such  contemplated  anastomosis;  but  this  relatively  seldom 
occurs.  The  stump  of  the  great  pectoral  may  be  left  an  inch 
long  (sometimes  longer)  in  order  to  permit  the  more  ready 
accomplishment  of  union  of  muscle  to  muscle.  On  the  other 
hand  the  deltoid,  as  just  stated,  is  dissected  as  far  as  it  is  to  be 
so  used  from  a  level  as  close  to  the  collar  bone  as  possible. 
I  have  found  three  medium  twenty-day  tanned  chromic  catgut 
sutures  to  be  quite  sufficient ;  and  the  entire  little  procedure 
adds  only  some  five  minutes  to  the  length  of  work.  As  a  rule 
it  is  easy  to  avoid  injury  to  the  cephalic  vein — the  preservation 
of  which  is  at  times  so  important — the  deltoid  slip  being 
fashioned  so  as  to  cross  obliquely  in  front  of  the  vein.  So  far 
as  I  have  been  able  to  determine,  the  portion  of  the  deltoid  enter- 
ing into  the  anastomosis  is  not  deprived  of  its  innervation,  nor 
does  it  undergo  atrophy;  though  obviously,  to  avoid  this,  it 
should  be  split  down  for  as  brief  a  distance  as  good  work  will 


c 


arcinoma. 


363 


permit.  On  the  other  hand  it  does  secure  what  is  intended, 
namely,  facilitation  of  flexion  and  adduction  of  the  humerus." 
While  this  device  of  Dr.  Dawbarn  is  entirely  original  and 
another  evidence  of  his  surgical  fertility,  it  is,  I  believe,  wholly 
unnecessary  and  intended  to  correct  a  condition  which  I  do  not 


Fig.  38.— Primary  incision  in  Tansini's  operation. 

think  exists.  There  is  no  trouble  about  patients  who  have  had 
their  pectoral  muscles  removed  adducting  the  arm,  or,  indeed, 
doing  anything  else  that  they  were  able  to  do  before  such  re- 
moval. I  have  already  expressed  my  opinion  fully  enough  on 
this  subject. 

Of  the  plastic  procedures  practised  by  foreign  surgeons,  I 
shall  describe  that  of  Tansini,  which  is  one  of  the  best. 
This  incision  has  been  imitated  by  other  surgeons,  but  the 


364 


Diseases  of  the  Breast. 


principal  feature  of  the  operation,  and  its  best,  viz.,  bring- 
ing the  flap  from  the  back  where  the  skin  is  presumably 
healthy,  undoubtedly  originated  with  Tansini.  I  have  never 
employed  it,  because  of  the  difficulty  of  its  execution,  the 
possibility  of  sloughing,  even  though  rightly  done,  and  the 
great  probability  of  its  occurrence  if  a  false  step  is  made. 


§1<2 
Fig.  39. — Second  incision  in  Tansini's  operation. 


In  Tansini's  operation,  the  broad  oval  incision  must  extend 
to  the  outermost  point  of  the  axilla  (Fig.  38)  so  that  the  narrowest 
portion  of  the  entire  wound,  that  is,  the  point  of  union  of  the 
two  incisions,  shall  be  there.  Thus  the  autoplastic  flap 
formed  by  the  second  incision  (Fig.  39)  will  cover  in  the  axillary 
space  in  such  a  manner  that  the  upper  extremity  of  the  cica- 
trices will  correspond  to  the  anterior  and  posterior  axillary 


c 


arcinoma. 


365 


borders  respectively,  the  center  of  the  space  being  protected 
by  healthy  skin.  The  flap  formed  by  the  second  incision 
must  be  6  or  7  cm.  (about  i\  inches)  in  breadth,  and  have 
its  center  corresponding  to  a  point  3  cm.  (1 1  inches)  from  the 


s>xc 


FlG.  40. — Showing  cicatrix  in  Tansini's  operation.     Front  view. 

posterior  axillary  border,  5  cm.  (2  inches)  from  the  spine  of  the 
scapula,  and  10  cm.  (4  inches)  from  the  angle  of  the  scapula. 
Its  anterior  border  is  outlined  by  cutting  from  the  termination 
of  the  first  incision  at  the  outermost  point  of  the  axilla  down- 
ward and  inward  towards  the  midline  of  the  back.  This 
cut  is  then  carried  horizontally  and  with  a  slight  curve  across 


366 


Diseases  of  the  Breast. 


the  back  and  upwards  to  a  point  opposite  and  6  cm.  (25-  inches) 
internal  to  the  point  of  starting,  thus  forming  the  posterior 
border.  This  flap  is  easily  drawn  forwards  and  made  to 
cover  the  defect  in  skin  caused  by  the  removal  of  the  breast, 


Fig.  41. — Showing  cicatrix  in  Tansini's  operation.     Side  view. 

and,  moreover,  as  already  stated,  supplies  the  axillary  space 
with  a  covering  of  healthy  skin.  The  dorsal  wound  is  closed 
by  a  series  of  linear  sutures.  A  small  area  at  the  lower  ex- 
tremity often  remains  open.    (Figs.  40  and  41.) 

As  first  practised  by  its  originator  this  operation  did  not 
give  invariably  good  results  owing  to  frequent  sloughing  of  the 


Carcinoma.  367 

flap,  sometimes  to  the  extent  of  one-third  of  its  surface.  A 
careful  study  of  anatomical  preparations,  however,  enabled 
him  to  overcome  this  disadvantage.  It  was  found  that  certain 
important  branches  given  off  by  the  dorsalis  scapulae  (arteria 
scapularis  circumflexa),  itself  a  branch  of  the  subscapular, 
are  contained  in  the  stem  of  the  flap.  This  vessel  passes 
between  the  teres  major  and  teres  minor  muscles  and  one  of  its 
terminal  branches  supplies  both  latissimus  dorsi  and  the  skin 
over  it.  In  addition  to  this  branch,  however,  the  latissimus 
dorsi  receives  branches  directly  from.the  subscapular. 

From  the  above  considerations  it  will  be  seen  that  in  order 
to  preserve  the  vitality  of  the  flap,  it  is  necessary  to  include 
the  latissimus  dorsi  and  to  insure  a  still  better  blood  supply, 
a  piece  of  the  teres  major  may  also  be  included. 

In  dismissing  plastic  procedures  in  general,  I  wish  to  state 
positively  that  the  prominence  given  them  is  out  of  deference 
to  the  opinion  of  many  surgeons  whose  judgment  I  value, 
and  also  to  meet  a  demand — with  some  a  paramount  one — 
of  securing  easy  primary  coaptation  of  the  wound.  That 
they  do  so  frequently  at  the  expense  of  an  abiding  result,  I  am 
now  fully  persuaded  after  a  fair,  and  I  think  I  may  say  con- 
scientious, employment  of  them  for  a  period  of  ten  years. 
They  are  inadequate,  disappointing,  and  do  not  meet  the 
pathological  requirements  necessary  in  dealing  with  an  infil- 
trating and  disseminated  malignant  process.  The  prime 
defect  with  all  of  them  is  that  they  subordinate  a  radical  cure 
to  the  carrying  out  of  a  preconceived  plan  which  will  do  very 
well  in  some  cases  where  the  lesion  is  favorably  situated,  but 
must  fail  in  many,  perhaps  most  instances  where  they  are 
practised.  I  cannot  doubt  that  he  who  employs  them  in 
many  cases  will  find  himself  sooner  or  later,  as  I  have  been,  the 
victim  of  chastened  hopes,  and  definitely  put  them  to  the 
one  side  as  alluring  and  convenient  for  the  surgeon,  but  an 
enormous  handicap  to  the  patient. 


368  Diseases  of  the  Breast. 

If  cancerous  growths  were  always  to  be  found  in  precisely 
the  same  situation  in  every  case  (instead  of  as  they  are  indiffer- 
ently, some  central,  more  peripheral,  and  about  an  equal 
number  in  each  of  the  four  quadrants  of  the  mammary  gland), 
then  I  could  easily  understand  how  a  skin  flap  could  be  so 
fashioned  as  to  meet  every  requirement,  surgical  and  patho- 
logical. But  with  growths  so  widely  variant  as  we  find  them  to 
be  in  carcinomatous  breasts,  there  is  but  one  safe  rule  to  follow, 
and  that  is  to  sacrifice  every  particle  of  skin  superlying  the  entire 
mamma.     Anything  short  of  this  is  simply  courting  failure. 

Palliative  Operations. — The  more  I  see  of  palliative  operations, 
the  more  I  am  impressed  with  their  uselessness.  I  have  about 
come  to  the  conclusion,  that  any  case  so  advanced  as  to  forbid  a 
reasonable  hope  of  complete  extirpation  of  the  disease  should  be 
treated  by  non-operative  measures.  I  have  no  hesitation  in  say- 
ing that  the  few  patients  upon  whom  I  have  performed 
palliative  operations,  hoping  to  relieve  pain  and  prolong  life, 
have  been  sadly  disappointing  to  me.  Pain  is  only  relieved 
for  a  time,  and  it  is  my  belief  that  the  end  is  hastened  rather 
than  delayed  by  partial  operations.  I  will  not  say  that  a  foul 
ulcerating  mass  may  not  be  removed  for  the  purpose  of  giv- 
ing temporary  comfort,  but  am  distinctly  of  opinion  that 
little  encouragement  should  be  given  a  patient  thus  affected 
either  as  to  decided  relief  from  pain  or  prolongation  of  life. 
I  would  much  rather  in  such  cases  do  a  still  more  radical 
operation  than  ordinarily  practised,  even  going  so  far,  as  I 
have  done  in  one  case,  to  remove  a  portion  of  the  sternum  and 
several  ribs  with  a  part  of  the  parietal  pleura,  if  there  seems 
the  least  hope  of  getting  beyond  the  apparent  limits  of  the 
disease.  In  the  case  referred  to,  life  was  undoubtedly  pro- 
longed by  the  heroic  measures  employed,  and  I  was  greatly 
surprised  to  see  the  woman  come  into  my  office  one  day 
when  I  had  supposed  her  dead  for  more  than  a  year.  She 
lived  nearly  three  years  after  my  last  operation. 


Carcinoma.  369 

The  recent  statistics  of  the  Johns  Hopkins  Hospital  just 
published  by  Bloodgood,  confirm  me  in  the  opinion  that  life 
is  undoubtedly  shortened  by  partial  operation,  as  such  patients 
live  only  2.2  years  if  operated  upon,  whereas  they  live  3.2 
years  without  operation.  Moreover,  such  operations  un- 
doubtedly do  the  cause  of  surgery  harm  on  account  of  the 
deterrent  effect  they  have  upon  operable  cases.  Patients 
are  sure  to  learn  of  them  and  do  not  understand  that  such 
operations  were  done  as  a  dernier  ressort  and  with  little,  if 
any,  hope  of  permanent  benefit  accruing  therefrom. 

Occasionally,  but  very  seldom,  in  my  judgment,  will  a  case 
be  encountered  where  Berger's  operation  must  be  considered. 
Within  the  past  six  months  such  a  case  presented  itself  to  me, 
and  the  accompanying  photographs  show  the  condition  of 
the  patient  prior  to  operation.  Her  plight  was  truly  a  pitiable 
one.  She  had  been  operated  on  by  another  surgeon,  and  there 
was  prompt  recurrence  in  spite  of  a  very  thorough  oper- 
ation so  far  as  I  could  judge  from  the  history.  Her  arm  was 
enormously  swollen,  it  being  more  than  double,  in  fact  nearly 
thrice  the  size  of  the  opposite  limb.  It  was  so  heavy  that  the 
patient  had  to  stay  in  bed  on  account  of  the  great  pain  occa- 
sioned by  the  weight  of  the  limb  when  she  was  up.  Her 
suffering  was  so  intense  that  I  finally  consented,  after  her 
urgent  and  repeated  insistence,  to  remove  the  arm.  The 
entire  scapula  and  outer  two-thirds  of  the  clavicle  were  also 
removed,  as  well  as  all  visibly  affected  soft  parts.  The  patient 
made  a  good  operative  recovery,  and  was  entirely  relieved 
of  pain  for  a  time,  moreover,  she  was  able  to  walk  about  the 
hospital  and  to  enjoy  a  degree  of  comfort  which  she  had  not 
known  for  months.  The  relief,  however,  was  of  brief  dura- 
tion, as  she  died  of  internal  metastasis  five  months  after  the 
operation.     (Plates  XL  and  XI J.) 

I  am  most  pessimistic  as  to  the  value  of  operations  in  cancer 
en  cuirasse.  Never  have  I  seen  good  result  from  them,  and 
24 


37°  Diseases  of  the   Breast. 

seldom,  in  my  judgment,  should  operative  measures  be 
employed.  1  can  easily  understand  how  the  lesions  might 
be  so  discrete  as  to  admit  of  removal  by  wide  and  free 
operation.  But  I  repeat,  such  cases  must  be  rare,  as  I  have 
not  seen  one. 

Treatment  of  Inoperable  Cases  by  Rout  gen-rays,  Etc — It  is  not 
my  purpose  to  go  exhaustively  into  the  subject  of  the  value  of  the 
Rontgen-rays  in  malignant  disease.  This  belongs  to  special  mon- 
ographs on  the  subject.  Briefly,  I  should  say  that  all  inoperable 
cases  may  be  treated  by  the  X-rays  and  that  some  will  find 
more  or  less  relief  from  pain  and  apparent  benefit  so  far  as 
reduction  in  size  of  the  tumor  is  concerned.  A  few  cases  are 
undoubtedly  made  worse  by  the  treatment,  the  growth  seem- 
ingly being  stimulated  to  an  unwonted  degree  rather  than 
repressed.  No  one  can  tell  what  is  to  be  the  result  in  any 
given  case  and  the  use  of  the  rays  must,  in  the  present  state 
of  our  knowledge,  "be  empirical. 

I  formerly  subjected  most  of  my  patients  after  operation  to  a 
certain  number  of  treatments  by  the  X-rays  and  then  believed 
such  a  course  warranted.  But  the  fact  that  I  have  seen  the 
disease  stimulated  and  made  to  pursue  a  more  rapid  course 
has  made  me  sceptical,  and  I  now  limit  the  use  of  the  rays 
to  inoperable  cases,  or  to  those  where  there  is  a  doubt  as  to 
the  complete  eradication  of  the  disease  by  operation. 

I  have  seen  the  best  results  follow  the  rays  in  superficial 
squamous  epitheliomata  and  lupus.  I  have  also  witnessed 
remarkable  results  occasionally  in  the  treatment  of  inoperable 
sarcomata,  but  I  fail  to  recall  a  single  case  where  the  X-rays 
exerted  more  than  a  temporary  benefit  in  a  case  of  cancer 
of  the  breast.  We  may  find  in  time  that  the  variety  of  the 
growth  will  influence  the  result  perceptibly.  They  apparently 
do  little  good  in  scirrhus. 

As  already  indicated,  the  X-rays  are  entitled  to  a  greater 
degree  of   confidence  in  the  treatment  of    inoperable  sarco- 


Carcinoma.  371 

mata  than  we  have  a  right  to  expect  when  dealing  with 
carcinomata.  I  have  not  used  this  treatment  in  sarcoma  of 
the  breast,  but  have  so  often  seen  gratifying  results,  occasion- 
ally astounding  ones,  from  the  use  of  the  rays  in  sarcomata 
located  elsewhere  that  I  should  be  inclined  to  advise  this 
treatment  in  any  case  where  operative  measures  were  clearly 
out  of  place.  W.  B.  Coley  has  cured  one  such  case  by  the 
use  of  his  toxins.  I  have  had  a  reasonably  large  experience 
in  the  treatment  of  sarcomata  elsewhere  by  Coley's  method, 
having  used  it  in  more  than  one  hundred  cases.  In  many 
there  was  prompt  and  distinct  betterment,  causing  me  to  be- 
lieve for  a  time  that  a  cure  might  be  effected.  In  only  one  case, 
however,  have  I  seen  such  a  result.  An  extensive  sarcoma 
of  the  pharynx  was  entirely  cured  by  the  use  of  toxins  and 
has  remained  well  for  more  than  ten  years.  When  the  treat- 
ment was  begun,  at  my  suggestion,  by  a  former  colleague,  Dr. 
M.  F.  Coomes,  of  Louisville,  Ky.,  it  was  my  belief  that  the 
patient  would  not  live  six  months. 

I  am  also  convinced  that  a  patient  with  sarcoma  of  the  parotid 
who  had  been  twice  operated  upon  by  a  New  York  surgeon, 
and  who  declined  a  third  operation,  fearing  paralysis  of  the 
facial  nerve,  which  she  was  told  would  almost  certainly  ensue, 
was  so  much  benefited  by  the  toxin  treatment  that  she  might 
have  been  cured  had  she  not  been  compelled  to  leave  here  and 
discontinue  the  treatment. 

I  consider  the  treatment  by  toxins  of  sufficient  value  to  be 
insisted  upon  in  all  clearly  inoperable  cases  of  sarcoma  and 
am,  moreover,  inclined  to  give  a  few  injections  as  a  prophylactic 
against  recurrence  after  operation,  even  in  favorable  cases. 

I  have  seen  no  good  whatsoever  come  from  the  toxin  treat- 
ment in  cancer,  though  I  formerly  used  it  in  many  cases. 


PAGET'S  DISEASE  OF  THE  NIPPLE. 

This  disease,  which  was  first  described  by  Sir  James  Paget, 
in  1874,  and  which  appears  in  the  nipple  and  areola  as  an 
eczematous  inflammation,  has  been  the  subject  of  much 
discussion  by  surgeons,  dermatologists  and  pathologists. 
Moreover  it  is  one  which  has  always  been  fraught  with  interest 
because  of  its  relation  to  cancer,  and  at  the  present  time 
particularly  it  has  attracted  renewed  attention  by  reason  of 
the  important  pathological  studies  which  have  been  made  of 
it  by  several  investigators. 

It  may  not  be  amiss  briefly  to  review  the  history  of  this 
disease  and  mention  the  more  important  theories  which  have 
been  advanced  relative  to  its  nature. 

Paget  himself,  basing  his  opinion  on  the  study  of  fifteen 
cases,  described  the  affection  as  a  disease  of  the  mammary 
areola  preceding  cancer  of  the  mammary  gland.  He  considered 
the  changes  in  the  skin  to  be  the  expression  of  chronic  irrita- 
tion, a  kind  of  eczema,  and  believed  that  this  supplied  a  soil 
favorable  for  the  development  of  carcinoma.  In  all  of  his 
cases  cancer  of  the  breast  developed  subsequently,  and  it  was 
this  circumstance  which  led  him  to  call  attention  to  the  disease. 
He  states  that  "for  an  explanation  of  these  cases  it  may  be 
suggested  that  a  superficial  disease  induces  in  the  structures 
beneath  it,  in  the  course  of  many  months,  such  a  degeneracy 
as  makes  them  apt  to  become  the  seats  of  cancer;  and  that 
this  is  chiefly  likely  to  be  observed  in  the  cases  of  those  struc- 
tures which  appear  to  be,  naturally,  most  liable  to  cancer,  as 
the  mammary  gland,  the  tongue  and  the  lower  lip." 

Paget's  opinion  was  accepted  for  a  considerable  period  of 
time. 

372 


Paget's  Disease  of  the  Nipple.  373 

In  1 88 1,  however,  Thin  published  his  paper  on  "Malignant 
Papillary  Dermatitis  of  the  Breast,"  which  he  stated  to  be 
the  same  disease  previously  described  by  Paget.  He  differed 
from  the  latter,  however,  in  believing  it  to  be  carcinomatous 
from  the  very  beginning,  and  that  the  original  location  of  the 
morbid  process  is  within  the  galactophorous  ducts.  He  declared 
that  the  involvement  of  the  epidermis  was  secondary.  Thin's 
theory  was  also  accepted  by  Duhring,  Raymond  Johnson, 
and  many  others  and  it  is  the  one  which  I  myself  accepted 
without  hesitation  as  announced  in  several  previous  com- 
munications on  the  subject. 

In  1889  Darier  enunciated  his  parasitic  theory,  in  which 
he  maintained  that  the  disease  was  due  to  infection  by  psoro- 
sperms.  A  year  later  Wickham  published  a  paper  in  which 
he  strongly  supported  Darier's  theory.  Darier  himself,  how- 
ever, later  changed  his  views,  but  notwithstanding  this  fact 
his  original  theory  has  continued  to  be  cited  from  time  to  time. 

Kaposi  expressed  himself  as  being  of  the  opinion  that  the 
disease  is  not  a  morbid  entity,  but  that  it  is  rather  an  obstinate 
form  of  eczema,  which  though  it  may  develop  into  cancer,  is 
yet  susceptible  of  cure.  Unna,  per  contra,  considers  it  to  be 
a  disease  sui  generis  differing  from  both  carcinoma  and  eczema, 
although  he  admits  that  it  may  supply  a  basis  for  the  de- 
velopment of  carcinoma.  Recent  careful  histological  studies 
have  served  to  increase  our  knowledge  of  the  true  nature 
of  the  disease.  They  will  be  discussed  when  we  come  to 
consider  its  pathology. 

In  regard  to  the  etiology  of  this  disease  little  is  known. 
The  vast  majority  of  cases  have  occurred  in  women,  although 
some  have  occurred  in  men.  Thus,  for  example,  Crocker 
observed  a  case  in  which  the  penis  and  scrotum  were  affected, 
and  Stelwagon  has  also  reported  one  in  which  the  disease  was 
confined  to  the  scrotum. 

In  this  connection  it  is  interesting  to  note  that  instances  in 


374  Diseases  of  the  Breast. 

which  parts  other  than  the  breast  were  attacked  have  been 
observed  in  the  female.  Holzknecht  mentions  one  in  which 
the  primary  location  was  probably  the  axilla,  and  Shield  saw 
one  which  affected  the  abdominal  wall. 

As  concerns  age,  the  majority  of  cases  occur  between  the 
fortieth  and  sixtieth  years,  although  some  have  been  observed 
in  women  as  young  as  twenty-eight  and  several  have  been 
reported  in  those  over  seventy. 

The  influence  of  heredity  is  unknown. 

The  influence  of  pregnancy  and  child-bearing  is  very  in- 
definite, if  indeed  they  have  any  effect. '  Cases  have  been 
reported  in  women  who  have  never  been  pregnant,  as  well 
as  in  those  who  have  borne  and  suckled  children.  It  is  natural 
to  suppose  that  the  irritation  of  the  nipple  caused  by  nursing 
might  predispose  to  the  development  of  the  disease,  but,  as 
already  stated,  nothing  definite  is  known  in  regard  to  the 
matter. 

Pathological  Anatomy. — If  a  section  of  the  diseased  tissue 
from  a  case  of  Paget's  disease  be  examined  under  the  micro- 
scope, a  collection  of  large  transparent  cells  will  be  observed 
in  the  deep  layers  of  the  epidermis.  These  cells  differ  from 
those  of  the  rete  Malpighii  in  that  their  protoplasm  is  much 
clearer,  and  they  are  also  larger.  They  have  several  nuclei 
which  stain  readily  and  are  rich  in  chromatin.  The  protoplasm 
is  often  vacuolated.  In  some  instances  the  cells  are  not  com- 
pactly arranged,  spaces  of  considerable  size  intervening. 
Schambacher,  however,  found  them  arranged  in  strands  which 
were  surrounded  by  an  envelope  of  connective  tissue.  The 
epidermis  is  thickened,  the  cells  small  and  atrophied.  Recent 
careful  observations  tend  to  show  that  there  are  no  transi- 
tional cells  between  the  large,  clear  so-called  Paget  cells  and 
natural  epithelial  cells  (Jacobaeus,  Schambacher).  Some 
investigators  have  thought  that  the  former  are  degenerated 
epithelial   cells,   but  more   careful  observations   have   shown 


Paget's   Disease  of  the  Nipple.  375 

that  such  is  not  the  case.  In  one  of  the  preparations  examined 
by  Jacobaeus  the  Paget  cells  were  found  to  be  continuous  with 
the  cells  of  the  glandular  carcinoma,  and  the  same  condition 
was  observed  by  Schambacher.  Furthermore,  they  were 
found  to  extend  to  the  superficial  layer  of  the  skin  in  areas 
where  the  disease  was  most  advanced.  Thus  it  is  seen  that 
there  is  a  direct  communication  between  the  morbid  process 
in  the  skin  and  that  affecting  the  gland,  and  it  is  surely  logical 
to  infer  that  the  disease  is  carcinomatous  from  the  very  begin- 
ning. No  convincing  evidence  has  been  adduced  to  show 
that  a  secondary  carcinomatous  degeneration  takes  place, 
and  it  was  mere  presumption  which  led  to  the  enunciation  of 
such  a  view.  As  already  stated,  I  have  always  maintained 
that  true  Paget's  disease  was  nothing  more  or  less  than  car- 
cinoma, and  I  am  still  inclined  to  believe  with  Thin,  Duhr- 
ing  and  others  that  the  disease  begins  in  the  galactophorous 
ducts  and  later  invades  the  nipple  and  areola  by  direct  ex- 
tension to  the  surface. 

A  contribution  to  the  study  of  Paget's  disease  made  by 
Schambacher  in  the  Deutscher  Zeitscrift  fur  Chirurgie,  No- 
vember, 1905,  is  of  such  importance  that  attention  must  be 
given  to  the  conclusions  drawn  from  the  study  of  this  case. 
Allusion  has  already  been  made  to  the  arrangement  of  the  Paget 
cells  in  this  specimen.  Taking  into  consideration  the  clinical 
course  of  the  disease  in  conjunction  with  the  pathological  find- 
ings, the  author  comes  to  the  conclusion  that  the  disease  was 
originally  an  intraepidermoid  carcinoma  which  invaded  both 
milk-ducts  and  skin.  He  considers  it  analogous  to  the  form  of 
•cutaneous  carcinoma  recently  described  by  Borman.  The 
cutaneous  lesions  in  addition  to  those  produced  by  the  malig- 
nant process  itself  he  found  to  be  due  to  inflammatory  infiltra- 
tion, which,  indeed,  predominates  in  the  skin,  and  it  is  this 
condition  which  gives  the  disease  its  eczematous  character. 
Schambacher  based  his  views,  so  far  as  the  clinical  aspect  of 


376  Diseases  of  the  Breast. 

the  malady  is  concerned,  upon  the  following  circumstances, 
which  I  deem  it  appropriate  to  mention  in  this  place..  The 
disease  began  with  the  formation  of  a  crust  upon  the  nipple 
which  finally  fell  off  and  left  a  reddened  inflamed  surface,  the 
redness  extended  to  the  areola  very  slowly  and  did  not  invade 
the  skin  of  the  breast  for  five  years,  no  evidence  of  disease  in 
the  mammary  gland  itself  was  detected  until  four  and  one-half 
years  after  the  lesion  on  the  nipple  was  first  noticed.  More- 
over, both  gross  and  microscopic  examination  showed  the  nipple 
to  be  the  part  most  severely  affected.  Indeed,  the  structure 
was  almost  completely  destroyed. 

These  considerations  are  certainly  worthy  of  careful  atten- 
tion and  should  afford  a  basis  for  still  further  observations. 

Symptoms. — Paget's  disease  apparently  begins  as  an  eczem- 
atous  inflammation  of  the  nipple  which  extends  concentrically 
to  the  areola.  Very  often  the  first  thing  which  attracts  atten- 
tion is  the  formation  of  one  or  more  small  grayish  scales  on  the 
nipple,  together  with  slight  redness  of  the  contiguous  parts  of 
this  structure.  This  condition  may  or  may  not  be  accompanied 
by  slight  itching  or  burning.  This  stage  of  the  disease  may  con- 
tinue unchanged  for  many  months.  A  notable  thing  about  it, 
and  one  which  is  important  from  the  standpoint  of  diagnosis, 
is  that  the  lesions  are  entirely  uninfluenced  by  the  ordinary 
remedies  to  which  mild  forms  of  eczema  not  uncommonly  yield. 
As  the  morbid  process  advances  the  areola  becomes  involved. 
Fissures  develop  and  raw,  eroded  spots  make  their  appearance. 
At  this  period  the  lesions  may  assume  a  moist  character,  or 
they  may  continue  to  be  dry,  much  like  psoriasis.  (See  Plate 
XLIII  and  Fig.  42.) 

In  some  cases,  the  diseased  parts  are  moist  almost  from  the 
very  beginning  of  the  disease. 

Both  of  these  forms  were  recognized  by  Paget.  His  descrip- 
tion of  well-developed  cases  cannot  be  improved,  so  I  will 
quote  it  verbatim.     He  states  that  in  the  majority  of  cases  "  it 


Paget's  Disease  of  the  Nipple, 


377 


had  the  appearance  of  a  florid,  intensely  red,  raw  surface,  very 
finely  granular,  as  if  nearly  the  whole  surface  of  the  epidermis 
were  removed ;  like  the  surface  of  a  very  diffuse  acute  eczema,  or 
like  that  of  an  acute  balanitis.  From  such  a  surface  on  the 
whole  or  greater  part  of  the  nipple  and  areola,  there  was  always 


Fig.  42. — Paget's  disease  of  the  nipple. 


copious,  clear,  yellowish,  viscid  exudation.  The  sensations 
were  commonly  tingling,  itching  and  burning,  but  the  malady 
was  never  attended  by  disturbances  of  the  general  health.  In 
some  of  the  cases  the  eruption  has  presented  the  characters 
of  an  ordinary  chronic  eczema,  with  minute  vesications,  suc- 
ceeded by  soft,  moist,  yellowish  scabs  or  scales,  and  constant 
viscid  exudation.  In  some  it  has  been  like  psoriasis,  dry,  with 
a  few  white  scales,  slowly  desquamating,  and  in  both  these 


378  Diseases  of  the  Breast. 

forms  I  have  seen  the  eruption  spreading  far  beyond  the  areola 
in  widening  circles,  or,  with  scattered  blotches  of  redness, 
covering  nearly  the  whole  breast." 

This  extensive  involvement  of  the  skin  has  been  occasionally 
seen  from  time  to  time  by  later  observers.  In  a  remarkable  case 
reported  by  Neisser  the  morbid  process  invaded  the  whole  side 
of  the  body,  passing  from  the  breast  to  the  sternum,  over  the 
shoulder  onto  the  back,  and  then  extending  anteriorly  to  the 
abdominal  wall. 

There  is  usually  a  distinct  line  of  demarcation  between  the 
healthy  and  diseased  parts.  Healing  may  take  place  in  cer- 
tain portions  of  the  diseased  area,  although  this  occurrence  is 
by  no  means  constant.  In  the  dry  cases  there  is  a  peculiar 
parchment-like  appearance  and  feeling  of  the  diseased  area. 

Retraction  of  the  nipple  occurs  as  the  disease  progresses, 
and  in  far  advanced  cases  the  nipple  may  be  nearly  or  entirely 
destroyed,  an  excavated  ulcer,  or  perhaps  merely  slight  depres- 
sion, taking  its  place. 

In  such  cases  more  or  less  involvement  of  the  axillary  glands 
will  not  uncommonly  be  detected.  The  integument  of  the 
axilla  may  also  be  somewhat  reddened  and  edematous.  Some- 
times instead  of  showing  ulceration  this  flattened  or  deepened 
surface  may  be  covered  with  scales. 

In  course  of  time  the  cancerous  nature  of  the  disease  invari- 
ably manifests  itself  in  the  tissues  of  the  mammary  gland. 
Paget  states  that  the  disease  of  the  nipple  was  followed  by 
cancer  of  the  breast  in  from  one  to  two  years.  Further  ob- 
servation, however,  has  proved  that  several  years  may  elapse 
before  gross  changes  in  the  mamma  itself  can  be  detected. 

The  most  important  thing  in  Paget' s  original  paper,  as 
he  himself  stated,  was  the  emphasis  placed  upon  the  invariable 
sequence  of  mammary  cancer  in  this  disease.  His  observations 
are  entirely  in  accord  with  our  present  belief  that  the  malady 
is  cancerous  from  the  very  beginning.     It  is  pertinent  to  this 


Paget's  Disease  of  the  Nipple.  379 

subject  to  state  that  a  vast  number  of  cases  reported  as  Paget's 
disease  were  in  reality  not  such,  but  were  of  such  slow  evo- 
lution as  to  lead  one  into  the  belief  that  they  did  not  par- 
take of  the  nature  of  cancer.  Thus,  no  doubt,  may  be  ex- 
plained the  small  percentage  of  cases  studied  by  Williams  in 
which  cancer  developed.  This  slow  evolution  which  character- 
izes some  cases  is  the  circumstance  above  all  others  which  gives 
some  plausibility  to  the  theory  of  intraepidermoid  origin  of  the 
cancerous  process,  to  which  reference  has  already  been  made. 

An  important  circumstance  in  the  natural  history  of  the 
disease  is  that  only  one  nipple  is  affected  at  first,  simultaneous 
eruption  of  the  morbid  process  in  both  never  having  been  ob- 
served. Cases  have  been  recorded,  however,  in  which  the 
second  nipple  became  involved  at  a  later  period,  or  after  the 
other  had  been  removed. 

In  contrast  to  what  has  already  been  stated  concerning  the 
protracted  course  of  some  cases,  it  may  be  said  that  there  are 
others  of  very  rapid  evolution  in  which  well-developed  signs  of 
glandular  carcinoma  manifest  themselves  within  a  few  months 
after  the  primary  lesions  of  the  nipple  and  areola  appear. 
Then  there  are  other  cases  which  remain  stationary  for  a  long 
period  only  to  advance  rapidly  to  glandular  involvement.  In 
some  of  these  cases  traumatism  has  been  blamed  for  the  sud- 
den progress  of  the  disease,  whereas  in  others  no  determinable 
causes  for  the  newly  assumed  and  unwonted  activity  were 
present. 

In  comparison  with  other  forms  of  cutaneous  carcinoma 
Paget's  disease  may  be  considered  comparatively  benign. 
Naturally  when  the  carcinomatous  process  has  extended  to  the 
glandular  structures  of  the  breast  the  prognosis  is  less  favorable. 

Diagnosis  should  present  no  difficulties,  particularly  in  well- 
marked  cases  which  have  existed  for  some  time.  Beginning 
cases  might  be  mistaken  for  simple  excoriation  or  eczema  of 
the  nipple,  but  the  failure  of  the  lesions  to  yield  to  the  ordinary 


380  Diseases  of  the  Breast. 

remedies — boric  acid,  salicylic  acid,  zinc  oxide,  etc. — should  at 
once  arouse  suspicion  as  to  the  true  nature  of  the  disease.  In- 
deed the  occurrence  of  lesions  such  as  have  been  described  under 
symptomatology  should  immediately  lead  the  physician  to 
suspect  Paget's  disease. 

Treatment. — The  treatment  of  Paget's  disease  is  entirely 
surgical  and  consists,  in  my  opinion  at  least,  in  early  amputa- 
tion of  the  breast  and  exploration  of  the  axilla  in  every  case. 
If  infected  it  should  be  thoroughly  cleaned  out.  I  cannot 
approve  of  partial  resection,  or,  indeed,  anything  less  radical 
than  that  which  is  believed  to  be  necessary  at  the  present  time 
to  successfully  contend  with  a  malignant  process  in  glandular 
structures  richly  endowed  with  lymphatic  vessels.  Every  theory 
worthy  of  the  least  acceptance  admits  the  malignant  nature  of 
the  affection  and  its  ultimate  tendency  to  involve  the  breast. 

The  only  difference  between  pathologists  is  where  it  begins. 
Clinically  this  is  negligible,  as  the  skin  is  very  early  involved 
in  cancer  of  the  breast,  and  it  is  reasonable  to  assume  that 
when  the  overlying  nipple  and  areola  are  involved  in  a  carcinom- 
atous process,  the  time  soon  comes  when  the  condition  of  the 
breast  must  be  questioned  on  account  of  the  free  communication 
between  said  structures.  It  is  then  carcinoma  of  either  the 
galactophorous  ducts  or  skin  primarily  with  certain  involvement 
of  both,  and  the  breast  as  well,  secondarily.  Therefore,  the 
future  safety  of  the  patient  will  be  menaced  by  temporizing 
agents  in  the  shape  of  lotions,  unguents,  caustics  and  electricity, 
and  scarcely  less  so  by  incomplete  operations. 


INDEX 


Abnormal  involution,  70 

See    also    under    General    Cystic 
Disease,  66 
Abscess,  acute,  30 
treatment  of,  33 
chronic,  41 

treatment  of,  42 
retromammary,  30 
treatment  of,  34 
Acute  cancer,  226 

mastitis,  29 
Actinomycosis,  63 
Adenocarcinoma,  186 

diagnosis  from  adenoma,  252 
Adenofibroma,    see    under    Peridnrtal 
Fibroma,  106;  also  under  Fibro- 
epithelial  Tumors,  103 
Adenoma,  simple,  121 

See  also  under  Fibro-cystadenoma, 
112;  Papillary  Cystadenoma,  114; 
and  Fibroepithelial  Tumors,  103 
Adenosarcoma,  163 
Alveoli,  during  lactation,  22 
Amazia,  14 

Anesthesia,  induction  of,  286 
Anesthetic,  choice  of,  286 
Angioma,  155 
etiology  of,  155 
morbid  anatomy  of,  155 
symptoms  of,  159 
treatment  of,  159 
Areola,  structure  of,  2 
Arteries  of  the  breast,  s 

of  the  nipple,  8 
Athelia,  14 

Amputation   of  the  breast,  for  benign 
tumors,  126 
for  carcinoma,  266 
for  sarcoma,  171 
for  suppurative  disease,  35 
for  tuberculosis,  54 
Anatomy,  1-16 


Anatomy,  descriptive,  1-5 

blood  supply,  5 

nerve  supply,  13 

lymphatics,  10 

structural  abnormalities,  14 
Atrophic  carcinoma,  196 
Axilla,  dissection  in  operation  for  can- 
cer, 275,  288 
Axillary  glands,  removal  in  operation 
for  carcinoma,  275,  288 

time  of  involvement  in  carcinoma, 

223. 
vein,  injuries  of,  392 

resection  of,  392 

Cancer,  173 

See  under  Carcinoma,  173 
Cancer  en  cuirasse,  195 

symptoms  of,  230 
Carcinoma,  173 

age  incidence  of,  176 
atrophic,  196 

course  of,  225 
author's  operation  for,  287 
axillary  glands  in,  202 

time  of  involvement,  223 

removal  of,  275 
bilateral,  183 
bones  in,  214 
brain  in,  216 
cachexia  in,  224 
concealment  of,  218 
curability  of,  254 

See  also  under  Prognosis,  253 
constitutional  disturbances  in,  224 
diagnosis  of,  235 

from  abnormal  involution,  249 

from  benign  tumors,  249,  252 

from  chronic  mastitis,  249 

from  cysts,  251 

from  sarcoma,  251 

from  syphilis,  250 


;8i 


382 


Index. 


Carcinoma,  diagnosis  of,  from  tuber- 
culosis, 250 
dissemination  of,  200 

by  permeation,  206 

through  the  blood,  211 

through  the  lymphatics,  201 
duration  of  life  in,  253 

See  also  under  Prognosis,  253 
edema  of  arm  in,  224 
en  cuirasse,  196,  230 
etiology  of,  173 

age,  176 

heredity,  180 

inflammation,  182 

injury,  182 

race,  179 

sex,  175 

social  condition,  181 
evolution  of,  217,  219 
examination  of  patient  in,  241 
fixation  of  breast  in,  220 
germ  theory  of,  173 
history  of  operation  for,  266 
inguinal  glands  in,  206 
inoperable,   treatment  of,    262,    263, 

264,  370 
in  negroes,  179 
in  young  women,  177 
Jackson's  operation  for,  326 
late  recurrence  of,  255 
lungs  in,  214 

mediastinal  glands  in,  205 
metastases  in,  200,  214 
microscopic  test  for,  247 
mucoid,  199 

of  the  male  breast,  175,  178,  182 
operations  for,    266   287,   322,   323, 
326,  361,  363 

mortality  of,  236 

requisites  of,  280 

technique  of,  282 
ovaries  in,  217 
pain  in,  217,  245 
palliative  operations  for,  368 
plastic  operations  for,  322 
post-operative  treatment,  319 
pathology  of,  186 

See  also  under  Varieties  0}  Carci- 
noma, 186;  Dissemination,  200 
pectoral  fascia  in,  205 
pleura  in,  214 
pleural  effusion  in,  224 
prognosis  of,  253 


Carcinoma,    relative     importance     of 
several  steps  of  operation,  280 
retraction  of  the  nipple  in,  220 
simplex,  192 
spinal  cord  in,  205 

spontaneous  fracture  in,  215,  218,  224 
sternal  symptom  in,  245 
supraclavicular  glands  in,  202 
symptoms  of,  217 
constitutional,  224 
local,  219 
Tansini's  operation  for,  363 
technique  of  operation  for,  282 
treatment  of,  259 
by  caustics,  262 
by  oophorectomy,  263 
by  operation,  266 
by  trypsin,  263 
by  the  X-rays,  261 
ulceration  in,  223,  225 
uterus  in,  217 
varieties  of,  186 
acute,  226 

adenocarcinoma,  186 
carcinoma  simplex,  192 
carcinomatous  cyst,  199 
gelatinous,  199 
medullary,  192 
scirrhus,  195 
Warren's  operation  for,  323 
withering,  196 

course  of,  225 
X-rays  for,  262,  370 
Carcinomatous  cyst,  199 
Cartilaginous  tumors,  150 
Caustics,  for  carcinoma,  262 
Chondroma,  see  under  Encondroma,  150 
Chondro-osteoma,  150 
Chondro-sarcoma,  150,  151 
Chronic  abscess,  41 

mastitis,  35 
Circle  of  Haller,  9 
Cystic     adenoma,    see    under    Fibro- 

cystadenoma,  112 
Cystic  disease,  general,  66 
treatment  of,  73 
with  associated  carrinoma,  73 
See  also  under  Chronic  Mastitis, 

35 
Cystic  sarcoma,  163 
Cysts,  64 

carcinomatous,  199 

dermoid,  81 


Index. 


383 


Cysts,  echinccoccus,  79 

hydatid,  79 

lymphatic,  65 

milk,  74 

retention,  64 

sebaceous,  82 

varieties  of,  64 
Colostrum,  definition  of,  18 
Congestion,  27 

treatment  of,  28 

Dawbarn's    method    of    transplanting 

pectoralis  major  muscle,  361 
Drainage  after  operation  for  carcinoma, 

397 
Dermoid  cyst,  81 
Diffuse  hypertrophy,  83 

etiology  of,  83 

pathology  of,  84 

symptoms  of,  84 

treatment  of,  86 

Echinococcus  cyst,  79 
Enchondroma,  150 

etiology  of,  151 

treatment  of,  152 
Endothelioma,  160 
Engorgement,  27 

treatment  of,  28 
Evolution  of  breast,  see  under  Puberty, 
Pregnancy  and  Lactation,  17,  18 

Fascia,    removal   of   in   operation   for 

carcinoma,  277 
Fascial  lymphatic  plexus,  11 
Fibroadenoma,    see    under    Periductal 

Fibroma,  106 ;    also  under   Fi- 

broepithelial  Tumors,  103 
Fibro-cystadenoma,  112 
Fibroma,  see  under  Periductal  Fibroma, 

106 

Galactocele,  74 

diagnosis  of,  79 

etiology  of,  75 

frequency  of,  74 

pathology  of,  78 

symptoms  of,  78 

treatment  of,  79 
Gelatinous  carcinoma,  199 
General  cystic  disease,  66 

Hydatid  cyst,  79 


Hypertrophy,  diffuse,  83 
etiology  of,  83 
pathology  of,  84 
symptoms  of,  84 
treatment  of,  86 

Inflammatory  diseases,  27,  42 
Intracanalicular  fibroma,  11 1 
Involution,  25 

abnormal,  70 

changes  in  breast  during,  25 

definition  of,  25 

Jackson's  operation  for  carcinoma,  326 
Keloid,  88 

Lactation,  persistent,  in  new-born,  17 

structural  changes  in  breast  during, 
22 

establishment  of,  21 

mechanism  of,  21 
Lipoma,  147 

etiology  of,  147 

intraglandular,  148 

retromammary,  148 

subcutaneous,  147 

treatment  of,  149 

varieties  of,  147 
Lymphatics,  cutaneous,  10 

deep,  10 
Lymphatic  cyst,  65 

plexus,  fascial,  11 

Maladie  noueuse,  69 

See    also    under    General    Cystic 
Disease,  66 
Male  breast,  anatomy  of,  15 

carcinoma  of,  175,  178,  182 
Mastitis,  acute,  29 

diagnosis  of,  31 

etiology  of,  28,  29 

parenchymatous,  30 

prophylaxis  of,  32 

superficial,  29 

symptoms  of,  31 

treatment  of,  $^ 

varieties  of,  29 
chronic,  35 

definition  of,  35 

etiology  of,  35 

pathology  of,  39 

symptoms  of,  40 


3§4 


Index. 


Mastitis,  chronic,  treatment  of,  41 
Medullary  carcinoma,  192 
Mucoid  carcinoma,  199 
Myxoma,  153 
Myxosarcoma,  166 

Nerves,  13 

Nipple,  absence  of,  14 

blood  supply  of,  8 

Paget's  disease  of,  372 

structure  of,  2 

Oophorectomy,    for    inoperable    carci- 
noma, 264 
Operation  for  benign  tumors,  126 
for  carcinoma,  author's  method,  287 
Jackson's  method,  326 
Tansini's  method,  363 
Warren's  method,  323 
history  of,  266 
relative  importance  of  several  steps, 

280 
technique  of,  282 
treatment  after,  319 

Paget's  disease  of  the  nipple,  372 

diagnosis  of,  379 

etiology  of,  373 

history  of,  372 

morbid  anatomy  of,  374 

symptoms  of,  376 

treatment  of,  380 
Palliative    operations    for    carcinoma, 

368 
Papillary  cystadenoma,  114 

age  incidence  of,  118 

diagnosis  of,  118 

morbid  anatomy  of,  114 

prognosis  of,  122 

symptoms  of,  118 

synonyms  of,  114 

treatment  of,  125 
Para -mammary  fat,  removal  of  in  oper- 
ation for  carcinoma,  278 
Pectoral    muscles,    importance    of    re- 
moving in  operation  for  carci- 
noma, 269,  276 
Pericanalicular  fibroma,  in 
Periductal  fibroma,  106 

morbid  anatomy  of,  no 

symptoms  of,  109 

prognosis  of,  122 

treatment  of,  125 


See  also  under  the  various  members 
0}  the  group 
Periductal  sarcoma,  163,  166 
Permeation,  theory  of,  206 
Physiology,  16 

Plastic  operations  for  carcinoma,  322 
value  of,  367 
resection  for  benign  tumors,  126 
Polvcystoma,  see  under  Fibro-cystade- 

noma,  112 
Polymastia,  14 
Polythelia,  14 

Pregnancy,  as  an  etiological  factor  in 
carcinoma,  181 
changes  in  breast  during,  18 
Puberty,  changes  in  breast  during,  1 7 

Retention  cyst,  64 

Retrograde  lymphatic  embolism,  206 

Retromammary  abscess,  30 

Sarcoma,  161 

age  incidence  of,  164 

diagnosis  of,  169 

etiology  of,  162 

pathology  of,  163 

prognosis  of,  171 

relative  frequency  of,  161 

symptoms  of,  166 

treatment  of,  171 

varieties  of,  162,  165 
Scirrhus  carcinoma,  195 
Sebaceous  cyst,  82 
Simple  carcinoma,  192 
Skin  grafting,  value  of,  274 

incision  in  operation  for  carcinoma, 
272 
Stiles' s  nitric  acid  test,  278 
Supraclavicular  glands,  removal  of,  in 

carcinoma,  270 
Syphilis,  57 

diagnosis  of,  59,  61 

etiology  of,  57,  58,  62 

frequency  of,  57 

initial  lesion,  varieties  of,  59 

secondary  manifestations  of,  60 

spirocheta  pallida  in,  6t 

tertiary  manifestations  of,  60 

treatment  of,  62 

Tansini's  operation  for  carcinoma,  363 
Transplantation    of    pectoralis    major 
muscle,  361 


Index. 


385 


Trypsin,  for  carcinoma,  263 
Tubercles  of  Montgomery,  2 
Tuberculosis,  43 

associated  with  carcinoma,  48 

diagnosis  of,  52 

etiology  of,  45 

pathology  of,  macroscopic,  46 

microscopic,  47 
prognosis  of,  53 
relative  frequency  of,  43 
symptoms  of,  51 
treatment  of,  54- 
by  operation,  54 
by  bacterial  vaccines,  55 
by  iodoform  injections,  55 
by  the  induction  of  passive  hyper- 
emia, 56 
varieties  of,  44,  46 
Tumors,  91 

benign,  characteristics  of,  95 
age  incidence  of,  100 
classification  of,  101 
mammary,  relative  frequency  of,  99 


Tumors,  cartilaginous,  150 
classification  of,  94 
definition  of,  93 
epithelial,  173 
fatty,  147 
fibroepithelia],  definition  of,  103 

etiology  of,  105 

general  considerations,  103 

prognosis  of,  122 

treatment  of,  125 
general  considerations,  91 
malignant,  characteristics  of,  96 

mammary,  classification  of,  102 
theories  of,  origin,  91 

See   also    under    Adenoma,    121; 
Carcinoma,  173;  Sarcoma,  161 

Veins  of  the  breast,  8 

Warren's  operation  for  carcinoma,  323 
Withering  carcinoma,  196 
course  of,  225 

X-rays,  for  carcinoma,  262,  370 


25 


Date  Due 

fX  _  /.  ?  ? 

1  8  ?Q fit 

MAY  0  9  ^ 

GOt 

APR 

1  0  QN\ 

9 

COLUMBIA  UNIVERSITY  LIBRARIES 


0041068483 


"^Mcb38-296 


